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FOOD, HEALTH AND GROWTH 



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THE MACMILLAN COMPANY 

NEW YORK • BOSTON • CHICAGO • DALLAS 
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TORONTO 



Food, Health and Growth 

A Discussion of the Nutrition of Children 



BY 

L. EMMETT HOLT, M.D., LL.D. 

PRESIDENT CHILD HEALTH ORGANISATION; FORMERLY PRO- 
FESSOR OF DISEASES OF CHILDREN IN THE COLLEGE 
OF PHYSICIANS AND SURGEONS, COLUMBIA 
UNIVERSITY, NEW YORK 




HEALTH IN EDUCATION \ Y I f EDUCATION IN HEALTH 



j|2tto gorft 

THE MACMILLAN COMPANY 

1922 

AU rights reserved 



PRINTED IN THE UNITED STATES OF AMERICA 






Copyright, 1922, 
By THE MACMILLAN COMPANY. 



Set up and electrotyped. Published June, 1922. 



Press of 

J. J. Little & Ives Company 

New York, U. S. A. 



JUN2I 1922 

©CI.A677228 






Dedicated to 
RAY LYMAN WILBUR, M.D., LL.D. 

PRESIDENT LELAND STANFORD 
JUNIOR UNIVERSITY 

PHYSICIAN, EDUCATOR AND 
ADMINISTRATOR 



PREFACE 

This little volume contains the Lane Lec- 
tures given at the Medical School of the Le- 
land Stanford Junior University in San 
Francisco in December, 1921. The lectures 
are published substantially as they were de- 
livered. 

The book is not therefore to be regarded 
as a text-book or even a systematic discussion 
of the aspects of nutrition which are here 
considered. But out of the wide range of 
topics relating to the nutrition of children 
certain ones have been chosen which seemed 
of special interest and importance at the pres- 
ent time, even though they are apparently 
not closely connected. 

Everything relating to the subject of nutri- 
tion and especially the food and nutrition of 
children has acquired a new interest in the 
last few years and much new knowledge has 
been added. The effort has been made in 
these lectures to present some of this in such 
a simple form as to make it available to the 
student of nutrition and the general reader. 



viii PREFACE 

It has not been thought desirable to burden 
the text with references to the publications of 
the authors whose work is mentioned in these 
lectures. I must, however, express my spe- 
cial indebtedness to the Report of the British 
Medical Research Committee upon Acces- 
sory Food Factors (Vitamines). 

The second and third lectures are based 
upon studies which have been carried on, 
chiefly at the Babies' Hospital during the past 
three years, jointly by the author and Helen 
L. Fales to whom acknowledgment is made 
for cooperation and assistance. The chemical 
work in connection with this study was done 
by Miss Fales, to whom I am also indebted 
for the tables of caloric food values in the 
Appendix, 



CONTENTS 



LECTURE PAGE 

I. Nutrition in Eelation to Growth, to 
Mental Progress and to Kesistance to 
Disease 1 

II. The Food Eequirements of Children During 

the Entire Period of Growth .... 47 

III. The Conditions Upon Which Are Based the 
Eequirements for Protein, Fat, Carbohy- 
drate and Mineral Salts. The Percent- 
age of the Different Food Constituents in 

the Diet of Children 87 

IV. Vitamines 149 

V. Practical Means by Which the Nutrition 

of Children May Be Improved 208 

VI. Appendix 263 

Index 269 



ILLUSTRATIONS 



9. 
10. 



FldUKB 

1. Nutrition and School Progress, Washington, D. C. 

2. Weight and School Progress, Detroit Boys 

3. Annual Gain in Weight and Height for Both 

Sexes 

4. Calories per Kilo, for Boys 

5. " " " " Girls . „ 

6. Total Daily Calories for Boys . 

7. " " " " Girls . . 

8. " " " 100 Individual Observations 
Proteins Eeinforced by Addition of Amino-Acida 



11. Grams Total Protein Taken Daily .... 

12. Percentage of Animal and Vegetable Proteins 

13. Percentage Distribution of Total Carbohydrate 

14. Growth with Diets Deficient in Mineral Salts 

15. Distribution of Calories Taken by Healthy Chil 

dren 

16. 
17. 
18. 
19. 
20. 
21. 
22. 
23. 

24. 



Distribution Total Calories — Boys 

" " " —Girls . . . 

" " "Per Kilo— Boys 

tt tt tt tt ct _Girls 

Effect of Addition of Milk to Purified Foodstuffs 

Growth on Diets Deficient in Vitamines . 

Deficiency of Vitamine " A" in Vegetable Oils 

Growth with Vitamine "B" from Different 
Plants 

Amounts of Foods Needed to Prevent Scurvy 



PAGE 

26 
28 



53 

68 

68 

74 

74 

81 

93 

95 

101 

104 

127 

136 

140 
143 
143 
144 
144 
153 
156 
160 

170 
182 



FOOD, HEALTH AND GROWTH 



Food, Health and Growth 

CHAPTER I 

Lectuke One 

Nutrition in Its Relation to Growth, to Progress 
in School and to Resistance to Disease. 

The problem of nutrition is older than the 
human race. It began when life began upon 
this planet. The survival of a species of 
plants and later of animals was conditioned 
upon their finding proper food and a favour- 
able environment. 

Not only the physical development of 
man but the fate of nations has been in the 
past in no small degree dependent upon 
their ability to solve the food question. 
This is true in peace times ; but in war time 
the problem of feeding an army or navy is 
quite as important as munitions. It was 
American wheat quite as much as American 
men which determined the outcome of the last 
war. 

1 



2 FOOD, HEALTH AND GROWTH 

Early in 1918 Lord Bhondda, the Brit- 
ish Food Controller, is reported to have said 
to the War Council: "Gentlemen, we are 
through. The Allies have lost the war. We 
are reaching the end of our food supply.' ' 
He cabled to Mr. Hoover that unless the 
United States could send an extra allowance 
of seventy-five million bushels of wheat the 
Allies could not hold out until the American 
troops should arrive. 

In many revolutions the food question has 
been the potent factor in stirring people to 
overthrow their government. 

As never before in modern times the sub- 
ject of food and nutrition has come to the 
SXritSJ front today. It is probably the most pressing 
proems* world problem. It was beginning to be felt 
even before the war; but greatly decreased 
production and consequent high cost of food 
have intensified conditions and made the 
situation more acute. We have often seen the 
results of prolonged underfeeding of indi- 
viduals. We are now witnessing the conse- 
quences of the underfeeding of whole nations. 
The glimpses which we are able to obtain 
from reports of conditions in Poland and 
China and, most of all, in Russia help us to 
realise this to a small degree. 
All unfavourable hygienic conditions, lack 



Children 



SUSCEPTIBILITY OP CHILDREN O 

of proper food particularly, bear most heav- 
ily upon children. They have less resistance 
than adults. They are more susceptible to 
infection, and the consequences of prolonged 
underfeeding are much more serious. With 
adults, underfeeding if not extreme in degree, 
even though prolonged, may greatly reduce 
efficiency without seriously or permanently 
impairing health. Not so with children. With 
them the food allowance must be not only 5Sat£» p " 
sufficient for energy and the repair of waste, Most 
but in addition a large allowance must be 
supplied for growth. Furthermore, there are 
certain food constituents essential for growth, 
and unless these are furnished in the food 
growth suffers even though the quantity of 
food is sufficient. 

The health, growth and physical develop- 
ment of children and to a considerable degree 
their mental development and progress de- 
pend upon their nutrition. 

It is for these reasons that I have chosen 
the nutrition of children, especially the food, 
health and growth of children, as the general 
topic of these lectures. 

The subject is a very broad one; all that 
will be attempted will be to point out some 
of the most important bearings of nutrition 
upon the life of the children, to bring to your 



4 FOOD, HEALTH AND GROWTH 

notice some of the results of the more recent 
laboratory studies which have shed new light 
upon this subject and finally to discuss the 
question of how malnutrition in children, as 
it exists in this country today, may be solved. 

We are continually reminded of the fact 
that in business there are too many middle- 
men, and that the public interest suffers in 
consequence. But is it not true that in science 
we have too few? There is, I believe, at the 
Middlemen present time, a need of one who shall stand 
science between the producer, that is the research 
worker in the laboratory, and the ultimate 
consumer, who may be the practising physi- 
cian, the health worker or the general public. 
Such a middleman I shall hope in these lec- 
tures to be. 

Health and normal nutrition are not quite 
synonymous terms ; yet as applied to children 
during the period of growth they are so 
closely allied that one may be taken as an in- 
dex of the other. While there may be normal 
nutrition without health, there cannot be 
health without normal nutrition. 

Nutrition in infancy has been given a great 
deal of careful study for the last thirty years. 
So successful has been the campaign both in 
this country and in Europe which has been 
waged against a high infant mortality, that 



REDUCTION OF INFANT DEATH RATE » 

some of the results seem little short of mar- 
velous. In New York City, for instance, the 
infant death rate has been reduced during 
this period practically to one-third the figure 
of a generation ago. The average for the 
last four years is 86 per 1000; formerly, in 
1880, it was 280 per 1000. This has been fSSSSie 

Remarkable 

brought about by the cooperation of many 
agencies; among which we may mention the 
pasteurisation or sterilisation of milk ; closer 
supervision and new standards for the pro- 
duction and handling of the milk supply; 
cleaner streets ; supervision of infants in milk 
stations and in their homes by visiting nurses ; 
a better understanding of the problems of in- 
fant feeding and hygiene both by the profes- 
sion and the laity; more rational and more 
intelligent treatment of infants acutely ill, 
and many others. Not much of this has been 
accomplished by legislative means ; most of it 
is the result of educational measures. These 

t . i ,. ,• -, p Educational 

have taken time, organisation, money and et- Measures 
fort. Not only the ignorant mother had to be important 
educated, but nurses, health officers and most 
difficult at times of all, the practising phy- 
sician. 

Success or failure in nutrition in infancy is 
soon evident even to the most unintelligent. 
It is not difficult to see whether a baby is 



Infancy 



D FOOD, HEALTH AND GROWTH 

thriving or not thriving. Death follows so 
regularly and often so soon npon failing nu- 
trition that even those least enlightened can 
hardly fail to connect cause and effect. 

Strangely enough, after this perilous pe- 
riod of the first two years of life was passed, 
vigilance as to health and nutrition almost 
ceased; very little attention has been given 
until the most recent years to these subjects 
during the remainder of the growth period. 
Not until a child entered school did he come 
children under any kind of public supervision. Some- 
Negiected thing was done then through the medical ex- 
amination of school children, but this has in 
most instances had for its object the exclusion 
of cases of contagious disease or the detection 
of defects of vision or hearing, or the pres- 
ence of large tonsils and adenoids or carious 
teeth. Observations upon the nutrition of 
school children have been until the last two 
or three years entirely omitted and the whole 
question ignored. 

The child of pre-school age has received 
even less attention than the school child — in 
most communities none at all except when 
acutely ill. 

One reason for the neglect of the child's 
nutrition after infancy has been that the ef- 
fects of failure are not evident at once, and 



DRAFT REVELATIONS I 

may not be for years. Although these chil- 
dren seldom die as a result of such failure 
they may be stunted in growth, under weight, 
anaemic, with feeble resistance to disease and 
altogether lacking in the physical energy 
which we call "animal spirits,' ' which make 
study, work and play a joy to the healthy hu- 
man animal. 

The first real awakening to actual condi- 
tions as to the health and nutrition of the ris- 
ing generation and their consequences was 
the result of the selective draft, in which, 
though exact figures vary in different states 
and communities, somewhere in the neigh- 
bourhood of 30 per cent of our young men 
were rejected as physically unfit for service. gjjS^— 
This was really the first general health inven- 
tory which had ever been taken in this coun- 
try. That similar results would have been 
found had an equal number of young women 
been subjected to a critical examination, can 
only be surmised. In the opinion of many 
even a worse showing would have been made. 

Since that time a number of extensive sur- 
veys have been made upon the health and nu- 
trition of school children. These have yielded 
results which correspond very closely with 
those obtained by the draft. The propor- 
tion of under-weight children and those suf- 



The Draft, 
the First 



8 FOOD, HEALTH AND GROWTH 

f ering from defects which affect nutrition and 
hamper growth has been found to be amaz- 
ingly large, in most communities fully 30 
per cent. 

The conditions mentioned are by no means 
confined to our large cities; those found in 
rural communities have been quite as bad, 
often worse. Nor are they seen only among 
the poor. Ignorance, indifference and neglect 
are far more important causes than poverty. 

It is admitted by all thoughtful persons 
that the greatest of all the resources of a na- 
tion are its children, but without any question 
it is the one which has been most neglected. 
"Where does the blame rest that we are allow- 
ing from six to eight millions of children in 
this country to grow to manhood and woman- 
hood with a physical development which ren- 
ders them quite unequal to meet the demands 
of modern life ? 

My own opinion is that the responsibility 
Response- for the neglect of the nutrition of children 
Neglected 1 can be laid partly upon the home, partly upon 
the state and certainly a share of it must be 
laid at the door of the medical profession. 

The failure of the home may be ascribed 
to several causes, probably the most impor- 
tant of which is the ignorance of parents 
themselves regarding often the simplest prin- 



Children 



FAILURE OF THE HOME V 

ciples of nutrition. We know about any sub- 
ject only what we have been taught either by 
our own experience or that of others. Some 
of this knowledge which relates to food and 
health is family tradition; some of it repre- 
sents racial custom. Much of it is the result 
of prejudice or even superstition and rests 
upon ideas long proven by modern science to 
be erroneous. 

In most homes a growing child is simply 
a member of the household. After the first 
two or three years he gets the same food as 
the adult members of the family. That there 
are certain needs of the body for normal 
growth which must be supplied in the diet 
of children, and which adults do not require, 
is something which most mothers have never 
heard. 

That the failure of a boy or girl to grow 
properly was in any way to be connected 
with the food given, if only it was abundant 
in amount, would seem to most parents 
absurd. 

Again, the weak indulgence of their chil- 
dren by many parents permits the formation 
of tastes and habits in the selection of their 
food, in the manner of eating, and their mode 
of life generally, which are quite incompat- 
ible with normal nutrition and growth. This 



10 FOOD, HEALTH AND GROWTH 

is a cause which will always be most difficult 
to remove. 

Economic conditions — poverty, intemper- 
ance, vice and general shiftlessness — are 
causes which will always exist as a basis for 
of d p C arents an irreducible minimum number of malnour- 
ished children. If most parents fail because 
of lack of knowledge who is responsible for 
teaching them? They will certainly go on 
repeating indefinitely the mistakes of their 
parents, unless some intelligent outside help 
is given. The public press has done a good 
deal in recent years, especially since the be- 
ginning of the Great War. Mothers have 
been taught something in clubs; something 
by visiting nurses in the homes and in clinics 
or hospitals; something by health literature 
distributed by private organisations, or pub- 
lic health agencies. In schools, older girls 
have been taught something about foods and 
cooking. But what has been done so far has 
barely scratched the surface. That so little 
has been accomplished, the medical profes- 
sion, I believe, is in no small degree to be 
blamed. For it is they who should be the 
teachers and the leaders in forming a public 
opinion which is absolutely necessary if the 
present conditions are to be materially im- 
proved. 



11 

But one sometimes hears the remark made 
— ' * doctors don 't know anything about health ; 
all their time and energies are devoted to a 
study of disease ; their interest is in disease, 
not in health." The medical schools have 
taught little or nothing about health, only 
about disease. That a knowledge of normal 
nutrition, which is the very basis of health, The 
is an essential part of a physician's educa- IKd ia be 
tion is a very recent conception. That his Te^ife 1 ? 1 
highest duty to his patients is to teach them 
the rules of health and how to obey them, is 
something very few physicians probably 
would admit. But is it not true as regards 
the children under his care ? 

In the past, the physician was consulted 
only in case of illness or accident; no one 
ever thought of seeking his advice at any 
other time. The physician's function was to 
relieve people of their aches and pains and 
help them on their feet. His office was the 
repair shop. If a mother felt the need of 
some advice regarding the diet of her chil- 
dren she asked her mother, some friend, or 
possibly a nurse, but seldom her physician. 
The chief reason why his advice was not 
sought in matters of diet and general hygiene 
was because it was discovered that about 
these things he knew very little more than 



12 FOOD, HEALTH AND GROWTH 

other people. The cause of this was in large 
measure due to a failure of the medical school 
where he was educated to take any account of 
these subjects, or it looked upon them as 
quite unimportant. 

But a decided change is gradually coming 
about. In the last few years there is one 
phase of nutrition which in most communities 
has come to be recognised as a physician's 
field, viz., infant feeding and hygiene. 

That there was more knowledge on these 
matters than was the possession of grand- 
mothers and gray-haired nurses, a large pro- 
portion of the young mothers of the present 
generation have come to appreciate, and an 
improved crop of babies and a great reduc- 
tion in the amount of sickness and death of 
infants has been the result. 

The possibilities in the prevention of dis- 
ease, not only in infancy but during the en- 
tire period of childhood and indeed through- 
out life, are just beginning to dawn even 
upon the medical profession. There still ex- 
ists, I regret to say, a large number of phy- 
sicians who look upon these modern move- 
ments in preventive medicine as something 
opposition ^ Q ^ d e p reca t e( ^ w hich is interfering, and 

MediSie they consider very improperly too, with their 
legitimate business. There is at present an 



THE PHYSICIAN'S DUTY 13 

organised body of physicians in New York 
City — I am glad to say not a very large or 
influential one — who systematically oppose 
public health measures upon this ground. 
Such a feeling is perhaps not unnatural, but 
cannot outlast the present generation of phy- 
sicians who, trained in the school of old tra- 
ditions, find it hard to adapt themselves to a 
changed order of things. 

That one of the most important functions 
of the physician is that of a health teacher, 
and also that one of the most important 
branches of education is health education, are 
two ideas which are rapidly coming to be ac- 
cepted by the most intelligent and forward- 
looking persons, but have not yet touched the 
majority of physicians or school superin- 
tendents and teachers. 

If there is any period of life when the ap- 
plication of science to health should show 
results, it is during the period of growth. A 
knowledge of the physiological and biological 
principles upon which normal nutrition rests childhood, 
must be given to the medical student. The tunity 
application of this knowledge in the super- 
vision and direction which it enables the phy- 
sician to give to those who have the respon- 
sibility for the physical welfare of children, 
should be regarded as not only one of his 



14 FOOD, HEALTH AND GROWTH 

chief duties, but as one of his greatest oppor- 
tunities. It is certainly the opportunity of 
the young physician. 

Has the Federal or State Government any 
share of the responsibility for the health and 
nutrition of children? If the home has ut- 
??th? uty terly failed and if the medical profession has 
not met the situation, it surely becomes the 
duty of the State to take a hand. How far 
shall the State go? Shall it be content sim- 
ply with efforts at enlightenment of the pub- 
lic, or shall it go further and exercise some 
sort of supervision, through the schools or 
the health authorities, of the physical de- 
velopment of children? These are questions 
which the future must decide. 

It has long been recognised as one of the 
legitimate functions of government to estab- 
lish and maintain experiment stations where 
methods of raising pigs, calves and poultry 
in the best and most economical way are 
studied and determined by experts. The 
Federal Government spent last year $9,700,- 
576 in appropriations for the Department of 
Animal Industry. This department has 
ernment" 4045 employees. The appropriation is nine 
liberally times as large as it was twenty years ago. 
Besides this, many states maintain separate 
experiment stations which are working at 



EXPENDITURES FOR HEALTH 15 

these same problems. All this expert knowl- 
edge is, through the bulletins issued, at the 
service of the smallest farmer in the most re- 
mote country district. 

What is the Government doing for the 
nutrition of the children! The Children's 
Bureau which was established in 1912 has a 
staff of about one hundred and the appropria- ^ t g° e J or 
tion for 1921 was $271,000. The Public Health cMidUT 
Service is principally concerned with epi- 
demic diseases, quarantine conditions and 
other problems in which the relation of health 
to commerce is especially close. Its appro- 
priation for the health of children last year 
was $40,000, most of which was expended in 
making surveys. 

In addition to what is spent by the Federal 
Government for health there must of course 
be added the amount appropriated by local 
authorities. The average annual appropria- 
tion for all health purposes of cities of dif- spend for 
ferent classes in the United States is as fol- 
lows : 

12 cities with population of over 500,000 $1.06 per capita 

12 " " " 250,000 to 500,000 1.04 " " 

56 " " " less than 250,000 72 " " 

24 " " " from 12,000 to 45,000 70 " " 

For most of these figures I am indebted to 
the Committee of the American Public 
Health Association. 



16 FOOD, HEALTH AND GROWTH 

There are good-sized towns in the East and 
in the Middle West whose total expenditure 
for health is less than fifteen cents per capita ; 
less than the average single admission to a 
moving picture show. 

Of course only a small part of this appro- 
priation has to do with the health of children. 
New York, which is more liberal than most 
cities, spends about one-sixth of its total 
health appropriation for children, or seven- 
teen cents per capita. 

If we estimate the worth of anything by 
what we are willing to spend for it, the value 
set upon health and especially the health of 
children in this country is not a very high 
one. 

While much has been done and is still be- 
ing done by private agencies to promote edu- 
cation in matters of health, we conceive it to 
be the duty of the State to make available 
for its humblest citizen the very best which 
modern science has discovered with respect 
to the nutrition of children. 

We insist in this country upon compulsory 
education of children (some of it pretty poor, 
it must be admitted). Is compulsory health 
HeK? sor7 for these school children a Utopian dream, or 
may we not hope that this may one day be 
realised, even in a democracy? 



FACTORS IN NUTRITION 17 

With conditions as they are today in the 
average home, and in the present state of 
medical knowledge and practice in the greater 
part of this country, surely the State must 
in some way come to the rescue of the chil- 
dren. WKether this can best be done through 
Federal, State or local authorities or by 
cooperation of all of these, as our roads are 
built, experience must determine. 

The nutrition of the child is dependent 
upon three factors : The character and quan- 
tity of his food ; his general hygiene ; and his 
inheritance. The last mentioned we cannot 
influence, but the other two it is quite within 
our power to direct and control. The prob- Health is 
lem of the nutrition of the child then is a Purchasable 
soluble problem to a very large degree. The 
slogan of the New York Department of 
Health, that "public health is purchasable,' ' 
is in no field so true as that which relates to 
the health of children. Upon the nutrition of 
the children depends very largely the future 
of the race from a physical standpoint, and 
one might almost say from an economic stand- 
point also. 

Every live thing that is young must grow; 
growth is evidence not only of health but of 
life. The growth of the body is conditioned 
by its nutrition. That not only the health 



18 



FOOD, HEALTH AND GROWTH 



Growth 
Determined 
by Food 



Food of 

Japanese 

Children 



but the size, weight, vigour, even the fertility 
of animals can be controlled by the kind of 
food given, has been demonstrated in many 
experimental laboratories. These points are 
most easily determined with small animals 
like rats or guinea pigs whose life cycle is 
a short one. That the same biological laws 
apply to the human race is beyond ques- 
tion. 

The opinion was once held that the stature 
of certain races was due to climate. It is 
now generally believed that these racial dif- 
ferences are chiefly the result of differences 
in food. Of course climate affects the avail- 
able food supply, so that indirectly it is an 
important factor. That the size of the Jap- 
anese is greatly influenced by their diet dur- 
ing the growth period can hardly be doubted. 

Dr. Hirai, Professor of Paediatrics in the 
Imperial University of Kyoto, writes me in 
the following terms in response to my inquiry 
concerning the usual food of children in 
Japan : 

"Rice plays the most important part in 
their diet after infancy. 

"No milk, cheese or butter forms a part of 
the regular diet. 

"The fat used is principally vegetable 
oils. 



JAPANESE CHILDREN 19 

"They rarely get meat but take much fish. 

"Green vegetables are extensively eaten, 
especially in summer. 

"They are fond of sweets and consume 
much of them. ,, 

This diet would seem clearly to be deficient 
in growth proteins and probably in the fat- 
soluble vitamine and in calcium. 

The curves for weight and height of Jap- 
anese children, for which I am also indebted 
to Professor Hirai, show some interesting 
comparisons with those of American chil- 
dren. 

During the first year almost no difference 
is seen. But after infancy when the general 
diet is taken, the divergence of the curves 
both for height and weight is very striking. 
I have had no opportunity to make personal , 

- if Japanese 

observations upon the growth of the Jap- JJgJj^g 
anese in this country; but statistics given in ^Tokii?* 11 
the Report of the Japanese Educational As- 
sociation of America, compared with those 
of the Educational Department of the City 
of Tokio, show that Japanese children in the 
United States, both boys and girls, are taller 
and heavier than those of corresponding ages 
living in Japan. This is evident in spite of 
the fact that although the Japanese diet has 
undoubtedly been much modified by residence 



20 



FOOD, HEALTH AND GROWTH 



Better Feed- 
ing and Hy- 
giene in In- 
fancy Pro- 
duce Better 
Children 



here, it is still very different from the Ameri- 
can diet for children. 

I can, however, speak from personal ob- 
servation npon the Eussian Jews. Those 
adults who come to the United States are for 
the most part scarcely taller than the Italians. 
But the children of the successful and pros- 
perous ones, those who have become to a con- 
siderable degree Americanised, are almost as 
large as those of our native-born population ; 
the children are frequently four or five inches 
taller than their parents. No such results 
of emigration, however, are seen among the 
very poor, whose food and mode of life have 
been little altered from those of their par- 
ents. 

It is my own observation, corroborated by 
most of the physicians with whom I have dis- 
cussed the subject, whose experience entitles 
their opinion to weight, that among the most 
intelligent classes, the generation of Ameri- 
can boys and girls, now fully grown, is larger 
and heavier than their parents. Newsholme 
states that the same thing has been observed 
in England in the boys at Rugby. This re- 
sult is due, I believe, to better feeding in in- 
fancy and early childhood, and no doubt to 
increased attention given to out-of-door in- 
terests during the period of growth. As yet, 



21 

however, these influences have affected only 
a small fraction of the children of the coun- 
try. Owing largely to a climate which gives 
greater opportunity for out-of-door life, the 
children of California are taller and heavier 
than those of corresponding ages living in 
the East and Middle West. 

To ignore the mental and moral aspects of 
eugenics and endeavour to breed a race of 
physical supermen and women is not exactly 
the program we would be understood as advo- 
cating. We do not in this age give so high a 
place as do savage and barbarous races to 
physical size and strength. It may not be 
thought necessary or even desirable that chil- 
dren should be as large as possible and grow 
to be large men and women. 

Happiness, usefulness and even success in 
life are by no means conditioned upon the 
height and weight of the individual. Still, 
a fine physical development is everywhere 
regarded as an asset of no mean value. The 
handicap in life of a frail body and habitu- 
ally poor health is a very serious one. We 
certainly owe it to every boy and girl to give 
them the opportunity to reach the best phy- 
sical development of which they as individu- 
als are capable. 

The effect of nutrition upon efficiency is 



Fine 
Physique 
an Asset 



22 FOOD, HEALTH AND GROWTH 

one of its most interesting aspects. In child- 
hood this is determined chiefly by the char- 
acter of the work done in school. There is 
not yet a great deal of reliable data available 
upon the relation of nutrition to school work. 
Most of those who have studied critically 
upon a large scale the kind of work done in 
school, have considered it from the point of 
view of the teacher rather than that of the 
physician. 

Studies upon retardation in school have 
hitherto dwelt chiefly upon other causes than 
health, such as late entrance, irregularity of 
attendance, etc. Even where health is con- 
sidered at all it is usually only referred to as 
illness which keeps a child from school or 
as defects of hearing or vision which inter- 
fere with school work. 
taxation 9 " -*- n scno °l language a retarded child is one 
that is below his grade for his age. Retarda- 
tion may be due to late entrance, but in very 
much the largest number of cases — fully two- 
thirds it is estimated — those who are retarded 
are so because they fail of promotion and are 
obliged to repeat the work of the grade. The 
problem presented by this group of children 
in our public schools becomes, when one real- 
ises its vast extent, a very important one to 
teachers and school superintendents. 



NUTRITION AND SCHOOL WORK 23 

Ayers, who has made for the Russell Sage 
Foundation a very exhaustive study of the 
problem of retardation in fifty-five cities, 
found the average number of retarded chil- 
dren to be 16 per cent of the pupils en- 
rolled. It is a question which involves on 
the basis of Avers' calculation some six mil- 
lions of children in the United States. The 
cost to the cities of the country alone in edu- 
cating this retarded group, Ayers estimates 
to be $27,000,000 a year. 

What particularly concerns us now is how J^^f* 
large a part health and general nutrition play 
in school retardation. In Ayers ' admirable 
monograph the subject of nutrition is not even 
mentioned. He did find, however, that chil- 
dren with physical defects made definitely 
slower progress than the average. 

The curriculum of the elementary schools 
is theoretically completed in eight years. The 
average time in which this was done in thirty- 
one cities studied by Ayers was nine and a 
third years. In six cities the average time 
was more than ten years. These were in 
every instance, I believe, cities with excep- 
tionally bad health records. While not estab- 
lishing a relationship between health and 
retardation these facts are certainly sug- 
gestive. 



Grade 



24 FOOD, HEALTH AND GROWTH 

As far back as 1893 Porter's observations 
in St. Lonis showed that the children who 
gave evidence in their school work of more 
weight and ^ an avera g e capacity, as measured by prog- 
ress in their studies, were both taller and 
heavier than their companions of the same 
ages whose work was inferior. He gives the 
weights of 1736 boys, eleven years old. They 
were in all school grades from the first to the 
sixth. The average weight increased regu- 
larly with the advance in grade. For 
example : 

The average weight of eleven-year-old boys in first grade was 63.4 lb. 
« " « " sixth " " 73.2 " 

Similar results were observed in the weight 
of girls. 

The average weight of thirteen-year-old girls in third grade was 75.2 lb. 
" « « " " " " " " seventh " " 88.4 " 

That there is a close correspondence be- 
tween physical development and mental prog- 
ress in school has been confirmed by no less 
than eighteen subsequent investigations in 
the United States, besides others published 
elsewhere from Canada, Germany, Eussia, 
etc. 

The following are some of the conclusions 
stated by those making the studies: 



NUTRITION AND SCHOOL WORK 25 

" Physical development and intellectual Physical 

,.,., , , , - ,, and Mental 

ability are closely connected.'' Develop- 

J , J ment Closely 

"Physical and mental conditions are in- Re iated 
terdependent. ' ' 

"Groups ahead in grade are taller and 
heavier than groups of average grade.' ' 

"Tall and heavy boys and girls are phy- 
siologically older and further advanced in 
school progress than those who are small 
and light." 

"School progress goes hand in hand with 
physical development. ' ' 

"Bright boys, as shown by school progress, 
are better developed physically and heavier 
for height than retarded ones." 

"There is a positive correlation betw T een 
physique and intelligence; the largest boys 
are in the highest grades." 

The conclusion reached by those who have 
studied this question is practically a unani- 
mous one, that mental development parallels 
physical development. 

Two recent investigations, one in Washing- 
ton and one in Detroit, deserve special notice 
because they have been made since the sub- 
ject of nutrition has been brought particu- 
larly to notice. 

In 1919 Bryant made under the auspices of 
the Child Health Organisation a survey of 



26 FOOD, HEALTH AND GROWTH 

the school children in Washington, particu- 
larly as to their nutrition. One thousand ten- 
year-old children were studied; this age be- 
ing the middle of the school period, it was 
thought would show an average of school 



NUTRITION AND SCHOOL PROGRESS - WASHINGTON. O.C. 



BOYS 



NUTRITION GOOD 



fl 



NUTRITION POOR 



-B- 



■ GIRL S 



NUTRITION GOOD 



5 

n 



13 

I 



NUTRITION POOR 



A 



] PER CENT OF CHILDREN MAKING RAPID PROGRESS- 



Fig. 1. 

conditions. She found ten-year-old children 
in all the grades from the first to the seventh. 
The proportion of those with good nutrition 
was twice as great in the three upper grades 
as the three lower grades. Among the boys, 
rapid progress, i.e., skipping one or more 
grades, was observed in 7 per cent of those 
well nourished and in none of those poorly 



NUTRITION AND SCHOOL WORK 27 

nourished. Slow progress, i.e., repeating one 
or more grades, was seen in 22 per cent of 
those well nourished and in 37 per cent of 
those poorly nourished. The difference in the 
school standing of the girls according to the 
condition of their nutrition was similar but 
not quite so marked. Among them rapid pro- 
gress was observed in 5 per cent of the well 
nourished as compared with 9 per cent of the 
poorly nourished. Slow progress was seen 
in 13 per cent of the well nourished and 
in 21 per cent of the poorly nourished. (Fig. 

1.) 

The conclusion reached from this study was 
that among boys, especially, poor nutrition £?£on N Es- 
distinctly handicaps progress in school;, ex- the^Best 01 

•n 'ii i i x. School Work 

cellence m school progress is dependent upon 
good nutrition ; a boy must be well nourished 
to attain more than average grade or go fas- 
ter than his fellows. 

A study was published in 1921 by Packer 
and Moehlman of a survey made in the City 
of Detroit, which covers observations upon 
height, weight, age and school standing of 
84,389 children. With but few exceptions, 
at every age from six to fourteen and a half 
years, the degree of retardation or accelera- 
tion in school work, corresponded very closely 
with the body weight. This is shown in the 



,28 



FOOD, HEALTH AND GROWTH 



WEIGHT AND SCHOOL PROGRESS, 
41.151 OETROIT BOYS. 



YEARS RETARDED 
A 3 2 1 0.5 



F 



WEIGHT ACCELERATED - PER CENT 
10.2 



7.1 




0.5 1 13 2 Z5 
YEARS ACCELERATED 



8.1 
WEIGHT RETARDED -PER CENT 

Fig. 2. 

chart (Fig. 2) which gives the relationship 
between weight and school progress of 41,151 
boys. The weight of 5987 boys who were in 
the normal grade for age is taken as 100 per 
cent. 



NUTRITION AND SCHOOL WORK 29 

The weight of boys retarded 1 year was 1.5 per cent below the 

average weight for the grade. 
The weight of boys retarded 2 years was 2.6 per cent below the 

average weight for the grade. 
The weight of boys retarded 3 years was 4.9 per cent below the 

average weight for the grade. 
The weight of boys retarded 4 years was 8.1 per cent below the 

average weight for the grade. 
The weight of boys accelerated 1 year was 2.6 per cent above the 

average weight for the grade. 
The weight of boys accelerated iy 2 years was 5 per cent above the 

average weight for the grade. 
The weight of boys accelerated 2 years was 7.1 per cent above the 

average weight for the grade. 
The weight of boys accelerated 2y 2 years was 10.2 per cent above the 

average weight for the grade. 

The accelerated children were for the most 
part in the lower grades. After the tenth children Be- 

x ° low Aver- 

year the number of the retarded, and of those jse wei^t; 
who were below average weight, steadily in- SJove en 
creased. At the age of fourteen and a half 
there were no accelerated children but many 
retarded and many below average weight. 
The charts for the girls were very similar, 
but a little less regular than those of the boys. 
In some of the upper grades, girls were more 
frequently found above average weight but 
below their grade than was the case with 
boys; but in both sexes these exceptions to 
the general rule were surprisingly few. 

These and many other data fully confirm 
all the other studies made upon the question, 
that, as a rule, children physically well de- 
veloped and well nourished do better school 



30 



food, Health and growth 



Good School 
Work Can- 
not be 
Expected of 
Mal- 
nourished 
Children 



work than those of inferior physique and who 
are undernourished. Poor nutrition, further- 
more, is a frequent reason for children be- 
ginning school late, and also for frequent ab- 
sences for minor illnesses to which these chil- 
dren are so liable. Both of these conditions 
tend to increase the amount of retardation 
seen in this group of pupils. 

The problem of the nutrition of school chil- 
dren and its bearing upon progress in school 
work is one whose importance teachers and 
school boards have not as yet appreciated. 
To expect an underfed, malnourished child to 
profit by educational advantages, no matter 
how superior these may be, is a grievous 
error. The old saying that it is hard for an 
empty bag to stand upright, is nowhere more 
true than here. You cannot fill the head When 
the stomach is empty; nor can you expect 
application or concentration of mind from an 
anaemic, nervous child who is fifteen or twenty 
pounds below normal weight. In such cir- 
cumstances a large part of the time and en- 
ergy of the teacher is wasted effort. 

An interesting study of the mental and 
nervous manifestations in school children as 
a result of malnutrition was made by 
Blanton of Wisconsin when he was with the 



NUTRITION AND SCHOOL WORK 31 

Army of Occupation. He made observations 
Upon 6500 children in Trier, Germany. He 
found that at least 40 per cent were suffering 
from malnutrition to a degree causing loss 
of nervous energy; double the usual number 
failed to pass their grades; the number do- 
ing superior work was reduced by one-half, 
and the number doing inferior work was in- 
creased by 50 per cent. The most striking 
symptoms noted among the malnourished 
children were (1) lack of energy; they were 
easily fatigued mentally and physically, 
would often fall asleep in school; (2) inat- 
tention, it was difficult to hold their minds to Nervous 
any subject but a few minutes at a time; (3) i/uSde?- 8 

1 1 • 4. J •«. • L nourished 

poor memory, closely associated with matten- children 
tion, for instance it took the children thirty 
minutes to memorise a few lines which or- 
dinarily could be done in half the time, and 
it seemed almost impossible to remember 
arithmetic; (4) slow comprehension; as one 
teacher put it, "it takes the children longer 
to think"; they found it difficult to follow 
explanations; (5) unusual restlessness, the 
children could not sit still, they either wanted 
to talk or giggle or whisper and it was diffi- 
cult to maintain discipline, and misbehaviour 
was common. Other groups were unusually 



32 FOOD, HEALTH AND GROWTH 

dull and quiet and immobile and seemed men- 
tally stupid. 

We all recognise this group of symptoms, 
they are familiar ones to every school teacher, 
but not always referred to their proper cause. 
Many of these children would be classed as 
mentally dull or stupid, proper subjects for 
an ungraded class, when the real cause is 
malnutrition. 

The conclusion seems to be fully justified 
that there is a physical basis for dulness or 
brightness in school work. If better work is 
to be done in school by the average pupil, his 
nutrition and physical development must be 
improved. In the large problem of school 
retardation I believe it will be found to be 
one of the most important factors ; that it has 
received so little attention in the past seems 
most surprising. 

The nutritional problem presented by the 
school child is part of the educational prob- 
lem, and must be recognised as such by both 
Nutrition, teachers and school boards. It might prove 

Part of ox 

the school a matter of economy if some part of the 
twenty-seven millions now expended in this 
country annually in teaching retarded pupils 
were devoted to health education and hot 
school lunches to improve their nutrition. 
An interesting sidelight upon the relation- 



RESISTANCE TO DISEASE 66 

ship between physical development and men- 
tal capacity is afforded by a study of the 
weight and height of defective children. In 
Goddard's report upon 6480 defective chil- 
dren from nineteen institutions it was shown 
that the physical deviation from the normal 
was regularly proportionate to the degree of 
mental deficiency. He concludes that there 
is a definite and a remarkable correlation be- 
tween physical growth and mental develop- 
ment. When large groups are considered, 
feeble mental capacity goes with small bodies. 

For the physician one of the most interest- 
ing phases of nutrition is its bearing upon 
the question of resistance to infection. Ex- 
perimental animals when deprived of certain 
foods, those containing the fat-soluble vita- 
mine, for example, show a great suscepti- 
bility to bacterial infections and a very high 
death rate from them, especially those of the 
lungs. 

"With the great majority of diseases the 
state of nutrition has a very important rela- 
tion to resistance to infection. This is shown 
both in laboratory experiments and in clini- and ne°- n 

i . sistance t 

cal experience. infection 

Dr. Trudeau's early experiments with 
tuberculosis afford an excellent illustration. 
Young guinea pigs in all respects as nearly 



34 FOOD, HEALTH AND GROWTH 

alike as possible were inoculated with tubercle 
bacilli in the same manner and with the same 
doses. One group had good food, sunshine, 
fresh air, in short all the conditions required 
for normal nutrition. The other group were 
given none of these things but were confined 
where they had to live under unhygienic and 
unfavourable conditions. The first group re- 
covered from their infection, grew and gained 
weight, thrived normally and when finally 
killed the lesions produced by the infection 
were found to be cured. They had entirely 
recovered. The second group lost ground 
steadily after inoculation and all succumbed 
to tuberculosis in the course of a few weeks 
or months. 

Upon these and similar experiments the 
whole modern treatment of tuberculosis has 
been built up. Our clinical observations con- 
firm the results seen in animals. Infection 
by the germs of tuberculosis is very wide- 
SStrfSn spread, but its active development in an in- 
vlioSSutof dividual is most frequently due to conditions 
cSoSs which have lowered bodily resistance by im- 
pairing nutrition. The campaign against 
tuberculosis has become essentially one for 
improving nutrition by food and personal hy- 
giene. 
The most striking illustration of diminished 



RESISTANCE TO DISEASE 35 

resistance to infection, owing to impaired nu- 
trition, is not only the remarkable increase of 
tuberculosis and all infections in children in 
those parts of Europe where war conditions 
bore most heavily, but also the very high 
mortality from these diseases. 

Nowhere perhaps is the influence of nutri- 
tion upon resistance to infection seen to a 
greater degree than in the common infections 
of infancy. A robust infant admitted to a 
hospital for a surgical condition may remain 
for weeks in excellent health. But the infant 
whose nutrition is much below the normal 
is so susceptible that, in spite of the utmost 
precautions, he contracts infections due to 
common pyogenic bacteria which excite in- 
flammations, especially of the respiratory 
tract, frequently with most serious conse- 
quences. 

It. is almost impossible in winter to keep 
such infants in a hospital ward more than a 
week or two without their developing rhino- 
pharyngitis, otitis, bronchitis or broncho- 
pneumonia. The difference in the way the 

, . a j • a i* - i Susceptibil- 

two types also react to infection is very great, ityoi Deii- 
The robust infant, as a rule, soon throws it dren to 

. iLfection 

off ; in the poorly nourished child, apparently 
mild infections frequently follow one after 
another until the child finally succumbs to 



36 FOOD, HEALTH AND GROWTH 

their combined effects. It is for this reason 
that hospitals for infants have such limita- 
tions in their usefulness. Eoomy wards with 
ample space between beds and, most of all 
the cubicle system of construction, will do 
much to lessen the dangers from infection in 
these susceptible patients ; but they can never 
altogether overcome them. 

Again, the outcome of attacks of pneu- 
monia, empyema, typhoid fever, or dysen- 
tery and many other infections is dependent 
in no small degree, first, upon the previous 
nutrition of the child and, secondly, upon 
our ability to maintain nutrition during the 
period of acute illness. 

Notwithstanding all the time and labour 
that have been expended in the search for 
specific remedies for disease, the list of those 
in which this has been achieved is a very short 
one. Malaria, syphilis, diphtheria, cerebro- 
spinal meningitis, and certain types of pneu- 
monia practically complete the list. 

For a long time to come, from present indi- 
cations, it will be the duty of the physician 
Maintaining to treat the patient suffering from the disease 

Nutrition r ° 

important rather than the disease itself: m the treat- 

Part of ' 

ofDiseasl men t of the patient we have come to realise 
that nothing is so important as to maintain 
his nutrition by careful feeding and hygiene. 



RESISTANCE TO DISEASE 37 

But it is not only the child who is much 
under weight whose state of nutrition renders 
him peculiarly liable to infection. There are 
large, fat, flabby children, especially infants, 
who seem quite as susceptible to infection 
and to exhibit as little resistance when in- 
fected. This appears to be related to the 
chemical composition of the body which to 
a certain degree is dependent upon the diet. 
Infants whose diet is excessive in carbohy- 
drates and low in protein and fat form one of 
these groups. The laity often make a dis- 
tinction between good fat and flabby fat. 
This idea contains, I think, a hint of the true children not 
explanation. It is well known that such a diet 
as that mentioned tends to a rapid increase in 
weight without a corresponding increase in 
strength. A familiar example of this type 
is the typical, condensed-milk baby. Observa- 
tions upon animals indicate that a consider- 
able part of this weight is due merely to ex- 
cessive retention of water in the tissues of the 
body, and that this is regularly increased by 
increasing the proportion of carbohydrate 
in the diet. Infants of the type mentioned are 
peculiarly liable to diseases of the digestive 
tract and show but little resistance when at- 
tacked. 

The rapid and almost incredible loss in 



38 FOOD, HEALTH AND GROWTH 

weight which these infants suffer with an 
acute diarrhoeal attack is of course due sim- 
ply to the draining away of water from the 
tissues, and in them the loss is much greater 
as the water held in the tissues is greater. 

In chronic disease during infancy and 
childhood the result depends very largely 
upon our ability to maintain normal nutrition. 
What has been said regarding tuberculosis 
applies almost equally well to cardiac dis- 
Matatenance ease during this period. This has been 
part L o a f g tii S © snown very clearly in the cardiac clinics in 
J/raSSL New York - Tne Problem of the child with 
H X eart Clironxc cardiac disease has come to be regarded as 
Disease very largely a problem in nutrition, and it 
differs in no very essential features from the 
problem of the undernourished child when 
the cause is a different one. Quite as impor- 
tant is constant supervision of diet and gen- 
eral hygiene, and even more important, the 
necessity for a proper adjustment of rest and 
activity. Provided nutrition can be main- 
tained with these patients during the period 
of growth, the great majority of them reach 
adult life with so little crippling that they are 
not seriously handicapped. But how differ- 
ent is the outlook for cardiac cases among the 
poor or ignorant, where the conditions of 
proper nutrition have been impossible or have 



NUTRITION AND REPAIR 39 

been neglected. Dilatation of the heart in- 
creases ; compensation soon fails. With treat- 
ment by rest, proper feeding and care their 
most aggravated symptoms are temporarily 
relieved, but too often soon return. The heart 
each time is left a little worse than before 
until finally the condition becomes a hopeless 
one and death follows. 

It is not then any special treatment which 
the average child with a cardiac lesion re- 
quires, but only continuous intelligent super- 
vision of his hygiene and nutrition. If these 
are neglected no amount of medication can 
prevent a steady advance in the pathological 
condition of the heart. 

Growth and repair, while not identical, are 
very closely related processes, and are influ- 
enced by much the same conditions. Repair 
after injury can take place at any age, but ^£ a r ir * f r ter 
it is much more active during the growth pe- gjJJJJJ In . 
riod. At all ages it is greatly influenced by Nut?it e ion by 
the state of nutrition of the patient. This is 
even more true of repair after the lesions of 
disease than after those produced by injury. 

In all organic disease recovery is greatly 
aided by the fact of growth. Provided nor- 
mal nutrition can be maintained, growth 
makes possible a degree of repair of organs 
damaged by disease to a degree that those 



40 FOOD, HEALTH AND GROWTH 

who are familiar with the repair of the adult 
organs can hardly appreciate. Within cer- 
tain limitations children may actually out- 
grow an organic disease. 

In all chronic disease in childhood the or- 
ganism has a twofold task: first, to combat 
the pathological process and repair the dam- 
age which it has wrought; secondly, at the 
same time, tdi provide for growth. It is 
often impossible for the body to do both these 
things, and growth is always what suffers. 
The effect upon growth of certain types of 
chronic nephritis is so marked as to give rise 
to the term " renal dwarfism." 

But when the pathological process is one 
which affects the organs specially connected 
with nutrition, like those of the digestive 
tract, the consequences are the most serious. 
As a result, in some disorders like that com- 
monly known as chronic intestinal indiges- 
tion in its severe form, growth may be ar- 
rested for years, so long, in fact, that it is 
never entirely made up and the child is 
dwarfed for life. " Intestinal infantilism" 
the condition is often called. 

When we turn now to consider the func- 
tional disorders of childhood the question of 
nutrition assumes a still more important role. 



Nutrition 



NUTRITION AND REPAIR 41 

The rapid growth of the brain and the de- 
velopment of the nervous system render the 
growing child peculiarly susceptible to ner- 
vous disturbances, whenever conditions of life 
are such as to interfere with normal nutrition. 
Most of the neuroses of childhood depend en- 
tirely upon disorders of nutrition. The head- 
aches, insomnia, disturbed sleep, chorea, habit u!lnlF§S£- 
spasm, hysterical manifestations and a mul- JfcSSKS' 
titude of others are relieved only by correct- Srdere? 18 " 
ing the faulty diet and habits which are the 
basis of the disturbed nutrition. 

The relation of nutrition to surgical results, 
surgeons are only just beginning to appre- 
ciate. Those obtained in chronic bone or 
joint diseases, for example, depend far more 
upon the patient's nutrition than upon the 
technical skill with which an operation is done 
or mechanical appliances used. 

The impulse of all young things to grow is 
a very strong one. It can be held in abeyance 
in various ways for considerable periods, 
when, if the conditions which have inhibited 
growth are removed, the loss can be made up. 
But if the cause continues to operate for 
too long a time, the normal growth response 
is no longer present and permanent dwarfing 
of the body is the result. 



42 FOOD, HEALTH AND GROWTH 

Experiments upon young animals prove 

wstSb^" that growth can be arrested at any time and 

Sg d for f Long for long periods simply by underfeeding, 

which may be done in a great variety of ways, 

withholding one or another of the necessary 

elements of food. 

It has been shown that with dogs, if the pe- 
riod of underfeeding did not continue through 
the entire period of adolescence, animals were 
still capable of growing vigourously; but if 
the inhibition extended through the custom- 
ary growth period, the capacity for growth 
was lost. A healthy young dog was kept 
for ten months upon a diet which did not 
promote growth, but was still sufficient 
to maintain weight. Afterwards the ani- 
mal was given a full diet. A considerable 
increase in weight occurred but very little 
growth. 

Osborne and Mendel's white rats grew vig- 
ourously after growth had been inhibited by 
underfeeding for as long periods as ten and 
twelve months. This represents in these ani- 
mals about one-third of the life cycle, and it 
is a longer period than is usually required to 
complete normal growth. 

Data are lacking as to what are the ulti- 
mate effects upon children of prolonged 
underfeeding. We constantly see in indi- 



PROLONGED UNDERFEEDING 43 

viduals early retardation of growth made up %°^ c ^ Be 
by abnormally rapid growth at a later period, Made u p 
when the cause of the retardation is not con- 
tinued and especially when the cause is not 
some organic or pathological condition. 

Children in Vienna recently observed by 
Noel and Paton of England showed an aver- 
age of 17.5 per cent below standard weight, 
some were as much as 27 per cent below. 
The group averaged 8 per cent below stand- 
ard height. These figures indicate that the 
children were nearly four years below normal 
weight and nearly three years below normal 
height for their respective ages. 

What will be the ultimate effect of six or 
seven years of underfeeding of the children 
in some of the European countries? That it 
will affect stature seems certain. Will it also 
affect fertility or longevity? We do not 
know. The powers of recuperation in child- 
hood are certainly very great. But there are 
limits beyond which nature will not go. It 
is probable thai; many permanent results men- 
tioned may be seen, particularly in individ- 
uals who were originally of poor physical its conse- 
stock. If to prolonged underfeeding we add manent 
chronic disease, which has developed in so 
many as a result of such feeding, and other 
unfavourable conditions, the inevitable con- 



44 FOOD, HEALTH AND GROWTH 

sequences would seem to be permanent stunt- 
ing of growth, a high mortality in early adult 
life, greatly impaired physical energy, low- 
ered mental capacity and premature old age. 

Enough illustrations have already been 
given to show that both to the physician and 
to the surgeon a personal knowledge of nutri- 
tion, or at least an appreciation of its impor- 
tance in the work of each of them, is abso- 
lutely indispensable if they would success- 
fully combat disease during the period of 
growth. To the nurse, the parent and the 
teacher also, a knowledge of the fundamental 
principles of nutrition is essential if they 
are to be equal to their responsibilities re- 
garding children. 

It remains to consider very briefly certain 
definite pathological processes which are pro- 
duced by failures in diet to supply some 
things which are essential to normal nutri- 
tion. The list of these so-called "deficiency 
diseases ' ' is not a long one, but they form an 
important group. 

In scurvy it is well established that its cause 
is a diet lacking in an essential accessory food 
substance — the antiscorbutic vitamine. In 
beri-beri, a disease rare in this country but 
common in certain parts of Asia, the cause is 
a lack of another of these substances, com- 



DEFICIENCY DISEASES 45 

monly referred to as the water-soluble vit- 
amine. A disease is produced in animals in 
which the most prominent symptom, inflam- 
mation of the eyes, goes on unless arrested to 
complete destruction of the organ and known £" e *° 4 M 

r o "Deficient' 

as xerophthalmia. A closely analogous Dlets 
one, if not identical with it, kerato-malacia, is 
met with in children. Both these conditions 
are due to a lack in the diet of another acces- 
sory food substance, known as the fat-soluble 
vitamine. 

There are two other common diseases of nu- 
trition — rickets and pellagra — which are 
closely associated with defective diets, but in 
which the evidence is not conclusive that they 
are due to a specific accessory food substance 
or vitamine. 

In forecasting the future of medicine as it 
relates to children it seems likely that prog- 
ress will be made as we are able to solve the 
problem of the acute infections, and that of 
nutrition. The problem of the acute infec- Sbmt/S?" 
tions is likely to be solved by measures of S^rIS* 
prevention rather than by the discovery of KtSSm 
specific forms of treatment. Preventive Growth 
measures will include not only sanitation, 
quarantine, isolation and the development of 
preventive sera, but quite as important per- 
haps as any of these, increasing the resist- 



46 FOOD, HEALTH AND GROWTH 

ance of children by improving their nutri- 
tion. This is the most hopeful field of pre- 
ventive medicine. 

With chronic organic disease we have in 
childhood almost nothing to do except as a se- 
quel of acute processes, which are usually the 
result of infection. 

In infancy fully half the total deaths are 
still directly traceable to disorders of nutri- 
tion. Though greatly reduced from former 
figures, infant mortality is still unnecessarily 
high. Improvement of conditions in infancy 
will be reflected also in improved results in 
early childhood. 

It is not too much to expect that with a 
better understanding of the subject of nu- 
trition there may be accomplished for the 
older child something comparable to what 
has been done for the infant. We may per- 
haps not see a greatly reduced death rate 
but we shall surely see a much higher stand- 
ard of physical development and general 
health. 



CHAPTER II 

Lectuke Two 
The Amount of Food Required by Children 

The food requirements of children have 
been discussed from many points of view. 
By different investigators various phases of 
this general subject have been studied. One 
group has been devoting its attention to basal 
metabolism,* or the needs of the body at rest. 
Others have taken up the study of the pro- 
tein requirement and the growth properties 
of certain proteins ; still others, the total food 
requirement for children in terms of calo- 
ries.** Just now the attention of investi- 
gators is focussed upon the accessory food 
substances — the so-called vitamines. 

The estimates which have been made re- 

* The term metabolism is used to cover all the chemical 
changes taking place in the body cells and in foodstuffs 
after absorption, before their products are eliminated. 

** A calorie is an arbitrary heat unit. It is the same 
whether the heat is produced from coal, gasoline, or food 
taken into the body. It is the amount of heat required 
to raise one litre of water (about one quart) from zero 
to 1° C. 

47 



48 



FOOD, HEALTH AND GROWTH 



garding the total food needs of children have 
sometimes been purely hypothetical, but more 
generally based upon the requirements of 
adults. Observations made during the last 
few years, especially in this country, have 
thrown new light on this subject. 

In reviewing the older literature, which is 
chiefly German, one is struck with the small 
number of the observations upon which their 
deductions have been based. The conclu- 
sions drawn from them do not seem war- 
ranted either by the number of their observa- 
tions or the conditions under which they 
were made. For instance, one author 
studied only a single child; another's obser- 
vations were made almost entirely upon his 
own children; a third based his conclusions 
upon observations of three children two of 
whShiifve whom were quite exceptional, being much 
over weight ; while a fourth made his studies 
upon children who were inmates of an in- 
stitution, most of them under weight. Yet 
these observations are quoted over and over 
again in textbooks and periodical literature 
and have been made the basis of very broad 
and widely accepted deductions. 

It is evident to all who study this subject 
that even in normal healthy children there 
are very considerable individual variations 



Small Num 
ber of Ob- 



Seen Made 



FOOD REQUIREMENTS 49 

in food requirements. In abnormal children, 
especially when observed under unusual con- 
ditions, these variations are of course much 
greater. 

The Different Factors. — In estimating the 
total caloric requirements all the different 
factors which go to make up this total must 
be taken into account. These are essentially to be con-" 
four: the requirements for basal metabo- 
lism, the needs for growth, the needs for mus- 
cular activity and finally the food values lost 
in the excreta. Unless all these factors are 
considered, serious errors will be made in our 
estimates. 

The first of these, the basal requirement, 
is fairly uniform for children of the same 
weight. The second, the growth requirement, 
differs at different periods of childhood. The 
proportion of the food required for growth 
is naturally greatest at the periods when 
growth is most rapid, viz., during the first 
two years and during adolescence. Growth 
variations are fairly uniform with all healthy 
children. When we come to consider the 
third requirement, the needs for muscular 
activity, we find great variations with indi- 
vidual children ; but in general, activity tends 
to increase steadily with age. The fourth fac- 
tor, the caloric value of the foodstuff lost in 



50 FOOD, HEALTH AND GROWTH 

the excreta, appears to be subject to very 
narrow variations with healthy children of 
the same age, unless there are very marked 
differences in the diet. 

Basal Metabolism. — Eegarding basal re- 
quirements, that is, the needs of the body at 
complete rest, a great deal of accurate in- 

The Needs n , • -i -, ij-ii* 

of the Body formation has been accumulated during re- 
Eest omp e ' cent years. This has been obtained by calori- 
metric observations, made in this country 
chiefly by Benedict and Talbot, DuBois and 
Murlin, and abroad by Rubner, Magnus-Levy, 
Heubner and others. The greatest number of 
observations have been made upon adults, 
both in health and disease, and upon infants. 
The intervening period from the end of the 
first year to the completion of growth has 
not been so generally investigated. Benedict 
and Talbot are the only observers who have 
studied systematically this entire period ; they 
have recently published the results of about 
250 observations made upon children of both 
sexes, more than half of whom were over 
one year of age. 

The range of individual variation in the 
values obtained was, as might be expected, 
considerable. Yet the number of observa- 
tions made is so large that the data seem suffi- 
cient to warrant us in accepting their results, 



FOOD REQUIREMENTS 51 

as representing the average for the period 
of growth. They have shown that the basal 
metabolism per kilo, of body weight is low 
in the newly-born infant and that it rises rap- 
idly until about nine months when the weight 
of eight or nine kilos, is reached. After that 
it slowly diminishes up to adult life. They 
found some differences between the basal 
needs of boys and girls. After a weight of 
10 kilos. — about one year — is reached, the SojSSsKty 
basal requirement of boys exceeds that of girls ? oSaSt 8 
until a weight of about 35 kilos, is reached, NineMonth* 
at about eleven years, when the basal needs 
of girls for a time are greater. 

The total basal requirement increases with 
age, but the relationship is best expressed as 
calories per unit of body weight, or of body 
surface. In the opinion of Benedict and Tal- 
bot there were no important differences be- 
tween caloric values expressed per unit of 
body surface and per unit of body weight. 
In our discussion therefore we shall use the 
unit of body weight as it is simpler and more 
convenient. 

The observations of others made upon a 
smaller number of children have yielded re- 
sults somewhat higher than those of Benedict 
and Talbot. After comparing all their fig- 
ures, however, it seems reasonable to accept 



52 



FOOD, HEALTH AND GROWTH 



What is 
Needed for 
Growth 



This Great- 
est when 
Growth is 
Most Eapid 



the values for basal requirement given by 
Benedict and Talbot as representing what 
they have termed "the irreducible minimum " 
which must be supplied to the human organ- 
ism for maintenance. 

Growth Requirements. — In considering the 
food requirements which must be supplied for 
growth, special growth needs, such as vita- 
mines or proteins which furnish the essen- 
tial amino-acids, etc., will not now be dis- 
cussed, but only the energy requirements for 
growth which are met by the fat, carbohy- 
drate and protein furnished in the ordinary 
articles of food. 

What is required for growth must, it is 
obvious, be greatest when growth is most 
rapid and diminish when growth is slower. 
How the growth rate diminishes during the 
early years and increases in the later years 
of childhood may be expressed by the annual 
increase in weight and height from birth up 
to the time when the body reaches its mature 
size. This average annual increase in weight 
and height is shown for both sexes in the ac- 
companying chart (Fig. 3). If we combine 
the curve representing the annual increase 
in weight, and that for the annual increase in 
height we obtain a curve which may be taken 
to represent approximately the annual in- 



Boys 



LBS. KILO. 
15.4 

132 



Girls 




lbs. 

15.4 
13.2 

110 

88 
66 
4.4. 
2? 



Clt 
24 

20 

16 

12 

8 



12345678910112131415161718-Year5-lZ345676Q10111Z13M1516ni8 
10 24 



f-c 



V?" 



737? 



lUVi 



20 
16 

12 

8| 



Hettjhi qttir. 



I 




nJ 

1234^678910llED14561TI8-Yedrs-12345678910111213i415i6I7B 



^g^?^ 



Cavuvnec 7 



Keioht 



IJihiJ iH 

1 23456769»1I£131415161718-Years*l 23456789101112131415161718 

Fig. 3. — The heavy black verticals of the two upper charts show the 
annual gain in weight in kilos, and pounds, and the gain in height in 
centimetres and inches, for both sexes. The lowest charts show values 
obtained by combining the two. 

53 






*■ f 



feg/'i 



IU 



54 FOOD, HEALTH AND GROWTH 

crease in the size of the body during the pe- 
riod of growth. This rate falls rapidly after 
the first year, but rises again after the tenth 
year in both sexes, reaching its maximum in 
boys at the sixteenth and in girls at the thir- 
teenth year when the rate is nearly twice as 
great as at ten years. 

In calculating the total caloric require- 
ments of the child in the past, it appears that 
sufficient consideration has not been given to 
these variations in the rate of growth. The 
increase in the body's needs for growth which 
must be supplied by the food is not uniform 
as age advances from early childhood 
through the period of adolescence. 

If we use as a basis for our calculation the 
annual increase in weight, it is possible to es- 
c!k>rit! ed timate approximately the number of calories 
Growth or needed for growth by a child at any given 
age and weight. Eubner estimates that about 
80 calories a day are needed to increase 
the weight of the body one kilo, in one year. 
If we multiply this value by the average in- 
crease in kilos, per annum it would give ap- 
proximately the number of calories needed 
daily at that age for growth. Thus a boy 
between the ages of four and eleven years 
who gains approximately 2% kilos. (5 
pounds) a year would require on the basis 



FOOD REQUIREMENTS 55 

of Rubner's calculation an average of nearly 
200 calories a day for normal growth. 

During the sixteenth year, when the aver- 
age gain in weight is 6.5 kilos, (about 14 
pounds) there would be needed for growth 
alone about 500 calories a day. After this 
time the growth requirement rapidly falls 
and when growth is completed, usually in 
the eighteenth year, it of course ceases en- 
tirely. We have found it impossible to verify 
in the laboratory the correctness of Rubner's 
method of estimating the caloric needs for 
growth, but clinical observations lead us to 
the opinion that his estimate gives results 
which are very nearly correct. 

Requirements for Activity. — When we 
come to consider the caloric allowance which 
should be made for muscular activity we SSts r fir 
meet the greatest practical difficulty. It is 
hard to estimate even approximately how 
many calories should be provided. Allow- 
ance must be made for all activity, whether 
productive or unproductive. Even the energy 
expended in the process of digestion must be 
taken into account. Benedict states that the 
energy needed to digest the food taken, uses 
up about 6 per cent of the total calories of the 
diet. This he terms the "cost of digestion.' 9 
Like the food value lost in the excreta it is 



Activity 



56 FOOD, HEALTH AND GROWTH 

one of the inevitable losses, and one for which 
allowance must be made in estimating the 
total caloric requirement of the child. 

The requirements of individual children for 

activity differ very greatly, more widely than 

they do in any other respect. A nervous, 

cMMrtn ttV0 lively, energetic child will use up many more 

Need More -i • • ,• • , ,-1 r> • j_ i • n 

Food calories in activity than one of quiet, placid 

temperament and indolent muscular habits. 
How great the difference is between the act- 
ual needs of these two types we can with our 
present knowledge only conjecture. 

Lusk has estimated that during the period 
from four to fifteen years the very active 
child requires more than double the total cal- 
ories of a quiet child. Since three of the four 
factors which make up the total, namely, 
basal requirement, growth requirement and 
the food value lost in the excreta, are nearly 
the same for these two types of children, it 
would appear that practically all of the in- 
creased allowance which he proposes, or con- 
siderably more than half the total food taken, 
is used up by the very active child in muscular 
activity. For young children this seems ex- 
cessive. It certainly cannot be taken as an 
average. 

The restriction of activity to conserve 
health and promote growth when food supply 



FOOD REQUIREMENTS 57 

is insufficient is both intelligent and scientific. 

We are told by Leonard Hill that many ActwiS* 

mothers in Germany when the food shortage Growth * 

was greatest were accustomed to keep their 

children in bed the greater part of the day, 

not allowing them to get up until eleven 

and putting them to bed at four o'clock. 

In general, a progressive increase in the 
calories which are needed for activity must be 
allowed as age advances. As soon as a child 
has learned to walk a great increase in ac- 
tivity takes place, and loss of weight occurs 
when no increase is made in the amount of 
food given, sometimes even in spite of it. 
The loss of the baby fat with the increase of 
activity which is seen in the third and fourth 
years is a familiar fact. With the normal 
healthy child activity increases pretty 
steadily with each year up to the period of 
adolescence. 

DuBois estimates that a man walking at a 
moderate pace on the level uses per hour 
about three times his basal caloric require- 
ment. On this basis, a boy of 30 kilos, caioriea 
weight, or about ten years of age, walking Moderate 
on the level for two hours, would require 
about 270 calories to supply the energy for 
this amount of activity. But such exercise 
would represent a small part of the energy 



How a Child 



58 FOOD, HEALTH AND GROWTH 

expended in a day by an average healthy boy 
of ten. 

The great difference in food requirements 
of children because of the difference in their 
activity is not in most cases sufficiently taken 
into account in providing their diet. If the 
increased caloric need of the active child is 
not supplied by the food, growth inevitably 
suffers. 

A child's food intake may be considered his 
physical income. Out of this certain over- 
ms y income head expenses must always be met first. 
These are, the needs of basal metabolism, the 
normal, necessary activity of life, and the 
loss in excreta. What remains may be spent, 
i.e., used up in excessive activity or saved, 
i.e., utilised for growth. Both of these he 
cannot do. Excessive activity is always at 
the expense of weight and growth unless the 
food intake is proportionally increased. 
Every physician and parent knows how diffi- 
cult it is to make the nervous, energetic, active 
child put on weight, even with the usual food 
intake and with a normal digestion. 

Loss in Excreta. — No accurate observa- 
tions on the food values lost in the excreta 
have been published regarding children over 
six years of age. Our own studies lead us to 
the opinion that this factor varies less with 



Excreta 



FOOD REQUIREMENTS 59 

age than do the other three factors which 
make up the total food requirement and that 
in health the loss of calories is equal to about 
10 per cent of the food intake for children 
of all ages after infancy. 

Extensive work done by the Department of 
Agriculture on the diet of adults has estab- loss m 
lished quite definitely that the loss in the 
excreta, when a mixed diet is taken, averages 
about 9 per cent of the total calories in- 
gested. Atwater and Sherman, who followed 
the metabolism of three six-day bicycle riders, 
found an average loss in the excreta of 9 per 
cent of the total calories taken. 

The most exact observations upon children 
past infancy as to the loss in excreta have 
been made by Miiller who studied thirty-two 
children from two to six years of age. In 
order to determine the exact food value lost, 
he dried the stool and urine of each child as 
well as a sample of the composite food of 
each and determined the exact caloric value 
of these substances by burning samples in 
a calorimeter. His estimation of the loss in 
the urine was calculated on the basis of its 
nitrogen content. His calculation gave an 
average total daily loss in the excreta of 
10.5 calories per kilo, which was almost ex- 
actly 10 per cent of the intake. 



60 



FOOD, HEALTH AND GROWTH 



Total 

Calories 

Required 

Estimated 

by Body 

Weight 



In our own observations we have found 
that healthy children under six taking a mixed 
diet have from 10 to 20 grams of dried 
matter in the daily stools. Using as a basis 
for calculation Miiller's average figure for 
the caloric value of the dried stool, and also 
his method of estimating the loss in the urine, 
we have found the combined loss in urine and 
faeces by healthy children from one to six 
years of age to be approximately 10 per cent 
of the calories usually given at the ages men- 
tioned. 

The loss through the excreta in children 
with disturbed digestion is much greater than 
this, and is of practical importance. We have 
found the loss in mild forms of chronic intes- 
tinal indigestion to reach 25 per cent of the 
total calories taken. The estimate of 10 per 
cent of the calories for loss in the excreta 
seems therefore a reasonable average allow- 
ance for normal children taking a mixed diet. 

Total Calories Needed. — Having consid- 
ered the four factors, let us now take up the 
question of the total calories, estimated ac- 
cording to body weight, or the calories per 
kilo. Not much work has been done in the 
determination of the caloric intake of chil- 
dren past the age of one year. In 1917 Gillett 
was able to collect from literature only 143 



FOOD REQUIREMENTS 61 

cases, and these were from eighteen authors, 
most of them German, in which this calcula- 
tion had been made. The number of observa- 
tions made by each author was small, and in 
several cases neither the condition of the chil- 
dren nor their environment was such as to 
permit us to draw general conclusions. The 
observations made have brought out many in- 
teresting facts, but they are not sufficient to 
warrant deductions as to the needs of the 
average child. 

For instance, two over- weight girls of nine 
and eleven years, studied by one author, took 
only 65 and 61 calories per kilo. Of three JJ^JgJ*" 
over- weight girls of eleven, thirteen and fif- 
teen years, studied by another, none took 
more than 45 calories per kilo; while some 
under-weight boys from two to six years old 
took an average of 113 calories per kilo. 

Camerer studied his own five children, four 
girls and one boy, for a period of years. In 
his observations made when the children were 
below seven years old, the results were about 
those generally accepted as average for the 
period. At a later period when the children 
were much older their intake was very low. 
At the age of fifteen it was only a little above 
the needs for basal metabolism as given by 
Benedict and Talbot. This is in spite of the 



62 FOOD, HEALTH AND GROWTH 

fact that the children were considerably be- 
low average weight; one cannot resist the 
conclusion that they were under weight be- 
cause they were under fed. Yet Camerer's 
results have been more widely quoted and 
used as a basis of feeding than those of 
almost any other author. 

The great individual variation in the total 
food intake of children is brought out by the 
observations of Tigerstedt, who found for 
example that the intake of nine children in 
the twelfth year ranged from 44 to 89 calo- 
ries per kilo. Since the weights of the chil- 
dren are not given it is somewhat difficult 
to interpret these wide variations. 

One of the most interesting and significant 
contributions to this subject is that of Gep- 
at st* Paul's hart, who made observations upon the boys at 
St. Paul's School at Concord, New Hamp- 
shire. The school contained about 360 boys 
whose ages ranged from twelve to seventeen 
years. 

The method he employed was quite differ- 
ent from that of most of the German observ- 
ers, and is the one which has been employed 
in studying the food consumed by soldiers in 
the army camps. It seems a reliable method 
of determining the average intake of large 
groups. 



FOOD REQUIREMENTS 



63 



Gephart first calculated the caloric value 
of all the food purchased during the period 
of observation, which was the entire school 
year. From this he subtracted the values ob- 
tained by analysing at various times the gar- 
bage and the waste. The remainder he di- 
vided by the total number of meals served, 
and thus obtained an average caloric value 
per meal for the school. 

In addition to the meals which were pro- 
vided by the school, the boys were accus- 
tomed to buy from a confectioner's shop con- 
trolled by the school, considerable extra food, 
chiefly sweets — chocolate, cakes, etc. The 
total amount purchased there during the pe- 
riod was known, and was apportioned by Gep- 
hart among the boys of the whole school. The 
calories furnished by this additional food 
were found to amount to about one-eighth of 
the total food consumed. 



Table 2 — Summary of Gephart 's Observations on Boys 
at St. Paul's School 





Average 
Age in 
Years 


Average Weight 


Average Calories per 
Kilo. 


Average 
Total 
Daily 

Calories 


School 


Kilos 


Pounds 


School 


Food 
Shop 


Total 


Lower .... 

Middle 

Upper 


13.5 
14.5 
16.1 


43.6 
50.8 
60.6 


96 
112 
133 


98 
88 
71 


15 
13 
11 


113 

101 

82 


4949 
5126 
4997 



64 FOOD, HEALTH AND GROWTH 

The average daily caloric intake was found 
to be about 5000 calories per boy ; and all but 
the group of the oldest boys took over 100 
calories per kilo. 

While the conclusions which might be 
G?ow C iBg e drawn from these observations may perhaps 
Mu^hlood be open to some question, still, the results 
show what amount of food is actually taken 
by the average American school boy at the 
ages studied, under the special conditions rep- 
resented by these observations. It is true 
that these conditions were somewhat excep- 
tional. The boys were living in a rigourous 
climate; they were taking much out-of-door 
exercise and they were at an age when growth 
is most rapid. 

Furthermore, the well-known disposition of 
boys of these ages, when not restricted, to 
eat apparently beyond their actual needs 
must also be taken into account. Still, when 
due allowance has been made for all these 
conditions, the fact remains that the enor- 
mous appetites of active, growing boys of 
the ages of those Gephart studied, represents 
a physiological need, which in the past has 
not been given sufficient consideration. 

Studies made on such large groups are 
likely, we believe, to give results much nearer 
the truth than observations made on a few 



FOOD REQUIREMENTS 65 

individuals or the children of one family, no 
matter how carefully such observations have 
been made. The results of the German 
studies to which we have referred would lead 
one to allow too little food for children dur- 
ing the active growing period. From obser- 
vation of the food habits of the average Ger- 
man one is inclined to believe that this de- 
ficiency is quite made up later in life. 

The Department of Agriculture has made 
many observations on the amount of food 
taken by families, including children, but has 
not determined what proportion of the food 
was taken by each child. They have appor- 
tioned the diets theoretically according to a 
commonly used system of coefficients ; for ex- 
ample, assuming that if a man takes one por- 
tion, a woman takes 0.8, a boy of twelve takes 
0.8, a boy of eight takes 0.7, etc. This method 
of calculation is open to serious objections.; 

Proposed Schedules of Calories per Kilo. 

Several of the authors to whom we have 
already referred have proposed complete 
schedules of caloric requirements per kilo, 
from infancy to adult life. 

Among the German authors, Camerer's 
schedule has been most often quoted as a 
standard. His allowance for boys is 89 calo- 



66 FOOD, HEALTH AND GROWTH 

ries per kilo, at the age of one year, this di- 
minishing to 75 calories at four years. After 
lave years the per kilo, allowance rapidly and 
steadily decreases to adult life. His values 
after six years are low, while after the 
a low twelfth year his allowance is below 50 calo- 

German ^ 

schedule r i es p er kii . As Benedict and Talbot have 
found the basal requirements at this age to 
be nearly 40, only 10 calories per kilo, are 
left for growth, activity and loss in excreta. 

Steffen offers a schedule for children up 
to six years of age in which he allows over 
100 calories per kilo, through this entire 
period. 

Uffelmann has proposed a schedule for the 
first five years of life. His values are lower, 
ranging from 88 calories per kilo, at one year 
to 68 at five years. 

Gillett and Sherman from the published ob- 
servations which they have collected have 
presented a table of values for total daily 
calories for children of both sexes through- 
out the entire period of growth. Their aver- 
age allowance for boys diminishes gradually 
from 95 at one year to 68 calories per kilo, at 
nine years and is kept at about that figure 
up to the age of fourteen. After this age the 
average allowance is rapidly decreased to 
55 calories per kilo, at sixteen years. Such 



FOOD REQUIREMENTS 67 

a decrease in calories per kilo, during the 
period of most rapid growth seems unwise. 

Lusk has proposed total calories per kilo, 
for three types of children : one for the quiet 
child, one for the active, and one for the very- 
active child. His values for the very active 
child are about twice those for the' quiet Differences 
child, ouite irrespective of age or weight. Ac- to Activity 
cordingly, his estimates for the calories for 
the active and for the very active child are 
extremely high for the early years, amounting 
respectively to 129 and 193 calories per kilo, 
for a boy of two years. The fall in calories 
per kilo, with increasing years is very rapid 
for all his groups. His values for the quiet 
child after the age of thirteen are very little 
above the requirements for basal metabolism 
and normal growth, leaving practically noth- 
ing for activity. This of course can never be 
reduced to zero. 

Fewer authors have given schedules for 
girls. In those of Gillett and Sherman and 
also of Camerer the allowance is consider- 
ably lower than that for boys; after the 
twelfth year that given is only a very little 
more than the needs for basal metabolism 
and growth. It is certainly quite inadequate. 

In the light of our own observations and 
from a study of those of others, theoretical 



Calories per "kilo for "Doijs 

Fbunds 

64 11 22 33 44 55 



Calories 



i Calories/ 




Kilos 35 10 i 15| |20j IS" 30j 35 >40 j 45 J50 55 j 60 65 |70 
Yeans 123456769101112 13 14 35 161718 Adult 



Calories per Kilo for girls 

Pounds 

& £ 11 22 33 44 55 66 77 86 

Calories 



110 121 132 




Calories 
140 



Kilos 33 JOj p, 120 

Tears i 2 345678910 11 12 13 14"1516l7i& Adult 

Fig. 4. — The solid vertical lines indicate weights in kilos; the broken 
lines, approximate weights at each year of age. The space between 
lines AA and BB shows allowance for basal metabolism; between BB 
and CC, that for growth; between CC and DD, that for muscular ac- 
tivity; between DD and EE, food values lost in excreta. The space 
between the lines AA and EE shows the total caloric allowance per 
kilo. 

Fig. 5. — The vertical and curved lines have the same significance as 
in Pig. 4. 

68 



FOOD REQUIREMENTS 69 

schedu'es indicating average calories per kilo, 
of body weight have been calculated for both Calorles 
sexes and are shown in Figures 4 and 5, pwkiio. 
indicating the total calories per kilo, for dif- 
ferent weights for approximate ages, also 
the proportion of the total which is allowed 
for each of the different factors which have 
been considered. 

It will be observed that the basal require- 
ment per kilo., adopting that of Benedict and 
Talbot, reaches its maximum at about the 
ninth month, after which it falls steadily 
throughout the entire period of growth to 
adult life. 

The calories allowed per kilo, for growth 
fall steadily from the first to the sixth year, 
remain practically constant up to eleven years 
for girls and thirteen years for boys, when 
a marked increase takes place 

This increased need is evident for about 
three years with both sexes, after which the 
growth needs rapidly diminish to zero. 

The needs for basal metabolism and for 
growth though subject to considerable indi- 
vidual variation are as averages practically 
irreducible. 

In the absence of definite data upon many 
points what should be allowed for activity is 
admittedly hypothetical. For reasons pre- 



70 



FOOD, HEALTH AND GROWTH 



Difficult to 
Estimate 
Accurately 
Needs for 
Activity 



Average Re- 
quirements 
Estimated 
According 
to Body 
Weignt 



viously discussed this has been increased 
steadily from the second to the thirteenth 
year for boys and to the twelfth for girls. 
Whether the allowance for activity should be 
further increased during the period of most 
rapid growth is somewhat doubtful. It is 
a matter of common observation that while 
the body is increasing so rapidly in size as 
it does at this time there is not infrequently 
seen in both sexes a growing disinclination 
to active muscular exertion, which is usually 
accompanied by a corresponding disinclina- 
tion to mental activity. For these reasons no 
increase in the caloric allowance per kilo, for 
activity has been made during these years 
of most active growth ; possibly even a slight 
reduction should be considered. 

The number of calories we have allowed 
for loss in the excreta after the first year of 
life is 10 per cent of the total. 

With the values proposed for the different 
factors just discussed, the total calories per 
kilo, are for both sexes about 100 at one year, 
falling to 93 calories per kilo, at two years, 
and to 80 at six years. This value we have 
continued for boys up to about the sixteenth 
year. For girls the calories per kilo, have 
been slightly increased during the eleventh 
year, since there is at this time an increased 



POOD REQUIREMENTS 71 

growth need and since the basal needs for 
this and the next few years are nearly uni- 
form. After the sixteenth year in boys and 
the fourteenth year in girls, the total calories 
per kilo, have been rapidly reduced to adult *flg* 
standard — about 48 for males and 44 for fe- 
males — since there is a rapid decline in 
growth needs and possibly some reduction in 
activity. 

The chief differences between this schedule 
for total calories per kilo, and others which 
have been proposed is that the per kilo, al- 
lowance is nearly uniform from the age 
of six to the end of the period of rapid 
growth. 

In the practical application of these sug- 
gested values it must be borne in mind that 
each component part of the caloric require- 
ment is subject to considerable individual 
variation. The curve suggested aims only 
to give averages. Activity is of course the 
most obvious variant. An extremely active 
child will undoubtedly utilise more calories 
than the average which we have allowed, 
while the needs of a quiet child may be sup- 
plied by somewhat less than the allowance 
made. 

Another cause for variation in the caloric 
requirement for the individual is the relation 



72 



FOOD, HEALTH AND GROWTH 



Under- 
weight Chil- 
dren Re- 
quire More 
per Kilo. 
Over-weight 
Children 



of weight to height and age. All observations 
show that the nnder-weight child will take 
and will utilise more calories per kilo, than 
the child of average weight; while, as might 
be expected, one who is over weight does not 
take and does not need the average number 
of calories per kilo. These facts must always 
be taken into account in the caloric allowance 
for an individual child. The average, how- 
ever, is not quite the same as the normal. 

An allowance of from 5 to 10 calories 
per kilo, both above and below the average 
allowance may be considered a normal range. 
When activity is excessive, however, an in- 
crease of 20 or even 30 calories per kilo, 
above the average may be well utilised. 

Camerer's schedule gives very little al- 
lowance for activity except between the ages 
of four and eight and after the age of thir- 
teen years practically none at all. 

The curve based on the average values of- 
fered by Gillett and Sherman does not differ 
greatly from the one here proposed up to the 
age of seven years. From seven to fourteen 
years it is nearly parallel with it, but is some- 
what lower. After fourteen years their curve 
falls rapidly. The allowance they have made 
both for activity and for growth during ado- 
lescence seems much too small. 



FOOD REQUIREMENTS 73 

Total Daily Calories. — Thus far only the 
calories per kilo, of body weight have been 
considered. In Figure 6 and Figure 7 
are given the curves which show the total 
daily calories allowed for healthy children 
of average, normal weights at the different 
ages, using the values above suggested. They 
also show for the different years the propor- 
tion of the separate factors which make up 
the total, viz., basal needs, growth needs, al- 
lowance for activity and for loss in the ex- 
creta. 

The daily calories allowed for both boys 
and girls are about 950 at one year. The in- 
crease with succeeding years is a little more calories 

. Needed at 

rapid for boys than for the girls until the age £^ rent 
of twelve is reached. From twelve to four- 
teen the total calories for the girls exceed 
those for boys. 

After fourteen the allowance for boys is 
considerably greater than that for girls. The 
highest values for daily calories are 3330 for 
girls at the age of fourteen and 4100 for boys 
at the age of sixteen. After these maximum 
figures are reached the values drop very rap- 
idly to adult standards for moderate activity 
— about 2640 for women and 3360 for men. 1 

1 Since this lecture was written some English figures on 
the metabolism of adolescents have been published by 



Cafoms Total dailu calories for bous 

5000 



4000 
3000 
2000 
1000 



Years 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 

Fig. 6. — The distance between the base and the upper line shows the 
allowance for total daily calories according to age, from birth to 
adult life. The spaces between the various lines, from the base line 
upward, indicate the allowance for the different factors which make 
up the total, namely, for basal requirement, growth, activity and loss 
in excreta. 





































































A 


X 


CO 


































$ 


/ 


:A 




































gr 


& 


















i 


>* 
























fcf* 


£ 











Calories 

4000 



Total dailij calories for qirls 




Years 1 2 3 4 5 6 7 8 9 10. 11 12 13 14 \5 16 17 18 19 20 



Fig. 7. — The curved lines and spaces have the same significance as in 
Fig. 6. 



74 



FOOD REQUIREMENTS 75 

These charts show the provision which 
must be made for the growth needs during 
the period of adolescence. The maximum 
growth need, calculated according to Buh- 
ner's formula previously referred to, for girls 
amounts to 380 calories daily during the thir- 
teenth year and for boys to about 500 calo- Growth 

Needs 

ries daily during the sixteenth year. This 
represents about 14 per cent of the food in- 
take. This greatly increased need for nor- 
mal growth at this period has not been suf- 
ficiently taken into account by most authors 
in estimating the total daily calories required. 
The large allowance for activity is of 
course the most debatable factor in the esti- 
mate presented. Some may think this allow- 
ance excessive but the more recent observa- 
tions, particularly those of Gephart, seem to 
justify the position taken. The total daily 
caloric allowance for boys of the age of 
those studied by Gephart is still much be- 
low the calories which he found to be actually 
taken by the St. Paul boys observed by him. 
However, as previously stated, these boys 
were no doubt living under rather exceptional 

Wright. His observations were made upon boys in training 
ships. The minimum daily intake recommended at thirteen 
and fourteen years is 3800 calories and fifteen and sixteen 
years 4100 calories, which corresponds very strikingly with 
the allowance here suggested. 



76 



FOOD, HEALTH AND GROWTH 



An Ado- 
lescent Boy 
or Girl 
Needs More 
Food than 
a Man or 
Woman 



conditions and the calories that were taken 
by them can hardly be used as a basis for 
estimating normal averages. 

According to the schedule presented, the 
allowance for activity varies from 6 per cent 
of the total calories during the first year to 
a maximum of 44 per cent of the total calories 
during the period of adolescence. This does 
not seem excessive for this active period. 

It is a common observation and undoubt- 
edly a true one, that during adolescence the 
average boy or girl takes more food than the 
average adult man or woman. Unquestion- 
ably this is proper and represents a real 
physiological need. It is only by assuming 
such values for calories per kilo, as have been 
proposed that one can reach a total daily 
caloric intake which will be in accord with 
these conditions. 

Other authors who have given complete 
schedules for food requirements have all 
steadily increased the total daily calories with 
age through childhood and adolescence up to 
the standard allowance for adults. No one 
has proposed a schedule according to which 
the values for total daily calories during ado- 
lescence exceed adult standards and fall to 
adult standards with the completion of 
growth. This seems to be absolutely neces- 



FOOD REQUIREMENTS 77 

sary; for unless this is done, the increasing 
growth needs must be deducted from the al- 
lowance for activity, leaving for the latter a 
very small remainder ; or, on the other hand, 
if activity is maintained, growth must suffer. Excessive 
The modern child, boy or girl, is usually an ^Spm 
active person during adolescence. If in of Growth 
school, he is required by school routine to take 
systematic exercise. If he has left school 
and gone to work, he is required continually 
to expend a good deal of physical energy. In 
view of these facts it is quite evident that 
the food taken by probably the majority of 
boys and girls of the class which leaves 
school at fourteen or fifteen years and enters 
industry during this period of rapid growth, 
is totally inadequate. 

After completing our theoretical schedule 
for total food requirements we have endeav- 
oured to test its accuracy by a study of the 
number of calories that healthy children liv- 
ing under good conditions actually took in 
their usual diet. In other words, having de- 
termined what children should take to meet 
the separate needs as we had calculated them, 
we next proceeded to find out if what might 
be considered normal healthy children did 
take anything like such an amount of food. 
This proved no easy task. As already stated, 



What 



Take 



78 FOOD, HEALTH AND GROWTH 

the observations upon such children reported 
in literature have been few in number. 

"We have at present collected over one hun- 
dred individual diet records of children from 
one to sixteen years of age — a sufficient num- 
ber to warrant some conclusions. They were 
selected children; chosen because they were 
ASffiua healthy, well cared for and normal as to di- 
^uauy 1 gestion. Almost all were children in private 
families, living in excellent surroundings. 
The parents were nearly all well-educated, 
interested in the purpose of our experiment, 
and willing to cooperate. Our aim was to 
learn what such children, fed, it was believed, 
intelligently, actually took in their accus- 
tomed diet, with the belief that the diet they 
were receiving was fairly typical of what is 
usually taken by well American children. 
They were not all from New York City. A 
number lived in the suburbs and some were 
from New England in the vicinity of Boston, 
so that the diet does not represent the ideas 
of any one physician or group. 

A report of the net weight, height, activity, 
appetite, general condition, etc. was obtained, 
together with a record of the exact amount 
ofEa?h pt °f eacn separate item of food taken by the 
rSur d cSL child for four consecutive days. From these 
Days ive data the caloric value of the average daily 



Complete 



FOOD REQUIREMENTS 79 

diet was calculated. Not only was the value 
for the total calories obtained, but also the 
distribution of the calories as fat, carbo- 
hydrate and protein, which, together with 
other facts brought out, will be discussed in 
the next lecture. We used for the most 
part established caloric values of the com- 
mon articles of food compiled by Locke. The 
values of a number of articles were calculated 
from the results of analyses made in our own 
laboratory. 

This method of estimating the calories 
taken by children is of course not absolutely 
accurate, but it undoubtedly gives a very close 
approximation. While there are slight vari- 
ations from the usual caloric values of the 
food taken, owing to differences in the meth- 
ods of preparation, it is probable that these 
errors tend to balance each other and that 
they do not materially affect the net result. 
We feel certain that in no case did the child ???lJw 
receive less food than was reported. It is gjgj ertlian 
not unlikely that in some cases a child actu- 
ally took more than was reported, especially 
some of the older children whose diet is not 
so carefully supervised and who are more 
likely to eat between meals without the knowl- 
edge of the parent. If there is, therefore, 
an appreciable error in the estimation it is 



80 FOOD, HEALTH AND GROWTH 

that the calculated amount is low rather than 
high. 

The largest number of the records were of 
children under eleven years of age. There 
are from five to twelve observations for each 
year up to the age of eleven. Beyond this age 
the number of observations for each year is 
too small to warrant definite conclusions, yet 
the results are interesting. 

In Figure 8 are shown the total calories 
taken daily by each of these children ar- 
ranged according to age. The curves shown 
are those based upon the schedules proposed 
for average daily calories at different ages, 
which have already been discussed. The 
curve for boys is indicated by the solid 
line ; that for girls, by the broken line. The 
individual observations for boys are shown 
by the large dots; those for girls, by small 
circles. 
Explanation This chart shows, as was to be expected, a 
wideva- considerable variation in individual observa- 

riations 

tions. However, for the most part they fall 
near the curves ; and up to the age of eleven 
the average falls very near the curves. Be- 
yond that age there are as yet too few ob- 
servations to be conclusive. However, those 
made on older boys are very close to the pro- 
posed curve. 




81 



82 FOOD, HEALTH AND GROWTH 

Some of the observations which vary most 
widely from the average curve deserve special 
mention. There were eight children whose 
total calories taken amounted to over one- 
third more than the theoretical average re- 
quirement; but every one of these children 
was reported to be exceedingly active. There 
were only two children whose total calories 
were more than one-third less than the theo- 
retical average requirement, but these girls 
were both very large for their ages, in fact, 
had nearly attained adult stature and accord- 
ingly did not need the number of calories for 
growth usual for that age. 

On the whole, it would seem that the curves 
suggested are approximately correct for the 
average caloric requirements up to the age 
of eleven years. We feel confident that a 
larger number of observations for the later 
years will verify the estimates for those years 
also. 

Summary rp Q gum U p our ^i scuss i on to this point, it 

is clear that in calculating the total caloric 
requirements of children there must be con- 
sidered separately the component parts of 
which the total is made up, namely, the re- 
quirements for basal metabolism, for growth, 
for muscular activity and food values lost in 
the excreta. 



FOOD REQUIREMENTS 83 

The great differences in the calculations of 
different writers who have estimated theo- 
retical values for total calories per kilo, for 
children, are in part due to the fact that they 
have not sufficiently considered the compo- 
nent parts which make up the total. 

The basal requirements per kilo, are high- 
est at about nine months and steadily fall 
from this time up to adult life. 

The food value normally lost in the excreta 
is a nearly uniform proportion of the intake, 
about 10 per cent, for all ages after infancy. 

The requirements for growth are greatest 
during the period when growth is most active, 
namely, during the first years of life and dur- 
ing adolescence. From the fourth to the tenth 
or eleventh year they are nearly uniform. 

The average for three factors — basal, 
growth requirements and food values lost in 
excreta — are nearly uniform for healthy chil- 
dren of the same weight living under similar 
conditions. The requirement for activity is 
the only factor which varies widely with dif* 
ferent individuals. 

The average caloric requirement of chil- 
dren is about 100 calories per kilo at an age Average 
of one year. For boys it falls to about 80 ments 
calories at six years and remains practically 
constant at this value up to the age of fifteen 



84 



FOOD, HEALTH AND GROWTH 



years as the increasing requirements for ac- 
tivity are offset by the reduction in basal re- 
quirements. After a weight of 50 kilos, (about 
fifteen years) is reached the calories per kilo. 



6 


Total 
Daily 

Calories 


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FOOD REQUIREMENTS 85 

can rapidly be reduced to adult standards, 
about 48 calories per kilo. The requirement 
for girls falls to 76 calories per kilo, at 
about six years and continues near this value 
until growth is complete, then falls rapidly 
to adult standards, about 44 calories per kilo. 

In this calculation there have been allowed 
considerably more calories per kilo, during 
adolescence than have been recommended by 
others. This seems to be necessary because 
of the increased growth needs at this time 
and the large requirement for muscular ac- 
tivity. 

According to our allowance the total daily 
caloric requirement of children of both sexes 
during adolescence exceeds by nearly 1000 
calories the requirements of the adult man 
or woman of moderate activity. 

Children who are under weight require 
more and those who are over weight fewei* 
calories per kilo, than those who are of aver- 
age weight for their age. 

The schedule here proposed is a tentative 
one and is based on present knowledge which 
is in many respects incomplete. There are 
a number of points which must be studied 
more fully before definite standards can be 
established. 

The practical value of such a standard is 



Standard 



86 FOOD, HEALTH AND GROWTH 

that it represents a normal average. Such 

Uses of an * , . 1 . . -,-, 

Average^ an average is or course not to be rigidly ap- 
plied to every individual child. Still an aver- 
age standard is useful; with this one may 
compare the diet of individual children who 
may not be thriving and also it may be used 
as a guide in providing for large groups of 
children in asylums, homes or large boarding 
schools, although perhaps it is less important 
than other factors in the diet to be considered 
later. 



CHAPTER III 

Lecture Three 
I. Protein Kequirement 

In the previous lecture the total caloric 
requirement throughout the entire period of 
growth was discussed. In the present one 
we shall consider somewhat in detail the 
different conditions which influence or which 
determine the amount of each of the impor- 
tant constituents of the child 's diet, — the pro- 
tein, fat and carbohydrate. 

All three of these nutritive substances are 
sources of energy * and may be utilised as 
such in the body. There are, however, other 
important considerations which affect the 
amount of each one of them in the diet. Es- 
pecially is this true of the protein. Before 
considering the other food elements it is de- 
sirable to establish first the protein require- 
ment. 

* Energy as applied to food may be expressed in terms of 
heat or mechanical work; it may be used up immediately 
or stored in the body for future use. 

87 



88 



FOOD, HEALTH AND GROWTH 



Proteins 

Are Very 

Complex 

Substances 

and Have 

Different 

Values 



The proteins are indispensable to life; no 
other foods can supply the nitrogen which is 
necessary for the constant renewal of the cells 
of the body. They are very complex sub- 
stances, being composed of some sixteen or 
eighteen different amino-acids. These amino- 
acids are sometimes called the building stones 
of the body. The proteins differ very much in 
their value as foods, according to the amount 
of the particular amino-acids of which they 
are made up. So that it is impossible to con- 
sider how much protein is needed during the 
growth period unless we also take into ac- 
count the kind of protein which is given. 

In the process of digestion the proteins of 
the food are split up in the intestines into 
their various amino-acids. These are ab- 
sorbed and subsequently recombined to form 
the proteins of the body. Now the pro- 
portions of amino-acids in the body proteins 
are not the same as in the food proteins. It 
follows therefore that not all the amino-acids 
of the food are utilised in building up the 
body structure or in making the repairs which 
the wear and tear of every day makes neces- 
sary. Those amino-acids which are not util- 
ised in this way as building materials are 
used largely for energy, being broken down 
into urea and excreted in the urine. 



PROTEIN REQUIREMENT 89 

The food proteins differ greatly in the 
ammo-acids they contain; they may, there- 
fore, furnish a considerable excess of one or ?™? 6 i£ f as 
more of those needed as building materials, f?r p <£i}Stii 
while at the same time they may be deficient AmSmt 
in others which are quite as necessary. Cer- 
tain of the amino-acids such as leucin, gluta- 
mic acid, arginin, prolin and others, which 
form a large proportion of the body pro- 
teins, are present in abundance in practi- 
cally all the proteins of the food; conse- 
quently an ample supply of these is always 
assured. 

But there are other amino-acids especially 
needed for growth, such as lysin, cystin and 
tryptophan, which are found in much smaller 
amounts, and in widely varying proportions 
in the different food proteins. Many of the 
food proteins are in fact entirely wanting in 
one or other of these particular amino-acids. 
Hence, special care must be taken to provide 
in the diet of growing children either those 
proteins having the larger proportions of 
these important amino-acids, or if the pro- 
teins which have the smaller proportions of 
these substances are given, they must be fur- 
nished in the diet in greatly increased amount. 
It is obvious, therefore, that the total protein 
requirement for children during the period 



90 FOOD, HEALTH AND GROWTH 

of growth is to a great extent dependent on 
the kind of the protein given. 

It is well known that the animal proteins 
resemble the proteins of the human body 
more nearly than do those of vegetable origin ; 
for this reason they are definitely preferable 
during the period of growth. For the child, 
therefore, the animal proteins, such as are 
furnished in milk, eggs and meat, are dis- 
tinctly of a higher grade than the vegetable 
proteins. With our present knowledge it 
seems necessary, if vegetable proteins are 
depended upon in the diet of children, to sup- 
ply them in larger amounts than when animal 
proteins are given and even then we may not 
secure normal growth. 

In estimating the child's protein need there 
DtffeS are two distinct functions of protein which 
S°Aduito S0 must be considered. The first is the require- 
ment for tissue repair and general mainte- 
nance ; the second is that needed for growth. 
In adult life the first need is the only one 
which has to be supplied. In childhood the 
second is quite as important. 

Even the protein requirement of the adult 
has been the subject of much controversy. It 
has been found possible to maintain nitrogen 
equilibrium, or a balance between intake and 
excretion, in an adult man or woman on a 



Needs of 



PROTEIN REQUIREMENT 91 

protein intake as low as 40 grams daily. J5SSSJS" 
There are some writers who believe that this of Adults 
minimum allowance is a sufficient supply. 
The average adult dietary, however, furnishes 
very much more than this ; as compiled from 
many sources it allows from 100 to 120 grams 
of protein daily. This amount, which may be 
considered as an expression of human experi- 
ence, has been regarded by many as the opti- 
mum protein need. This amount of protein 
allows an average of about 1.4 grams of pro- 
tein per kilo, of body weight. 

Sherman, who has recently investigated the 
average protein intake of over 100 adults, 
found the average minimum to be 44.4 grams 
per day. This represents about 0.6 gram 
per kilo, for a person of average weight. His 
conclusion is that for an adult 1.0 gram of 
protein per kilo, is quite enough for main- 
tenance. 

The question has been much debated 
whether this maintenance need can be en- Aw<liia , ^ 
tirely supplied by vegetable proteins. The SSJ-S 16 
work of a number of investigators indicates 
that this is possible. Sherman, however, be- 
lieves that better results are obtained by sup- 
plying part even of the maintenance require- 
ment by animal protein. Among the vege- 
table proteins there are certain ones, notably 



92 FOOD, HEALTH AND GROWTH 

zein, a protein of corn, which are insufficient 
even for maintenance. 

From what we know of the adult protein 
need it may reasonably be inferred that the 
growing child with his more active metabo- 
lism requires for maintenance from 1.0 to 1.5 
grams per kilo, of body weight daily. It 
seems probable that this can be supplied 
either from vegetable or from animal 
sources. 

In addition to the maintenance need, how- 
ever, the child must be supplied with a gener- 
Animai °us allowance of protein for growth. Because 
|est e S? the vegetable proteins as a group are so poor 
in certain of the important amino-acids, it 
seems necessary to supply the protein needed 
for growth by animal protein. It is quite pos- 
sible then that an adult might be kept in per- 
fect health upon a vegetarian diet; but it 
is extremely doubtful whether such a diet for 
a child would insure normal growth. How 
much protein should be furnished to cover 
the growth requirement it is difficult to esti- 
mate. 

No experimental work has been reported on 
the protein need of children and the effect 
on their growth of either a very low or a very 
generous protein intake. Osborne and Men- 



Growth 



PROTEIN REQUIREMENT 93 

del have been able to obtain very definite 
quantitative results on protein needs in their 
work with rats. These are not only interest- 



Effect of 

Different 
Proteins on 
Growth 
of Rats 



PROTEINS REINFORCED BY ADDITION OF AMINO ACIDS. 



nun ttQWTM «ITII CLIWI 



•••• CMWTH WITH KM AM SLIUM s ... - 


■ Ml ITIIW 
















....-- 














.♦, 




4 




120 




... — • 









r 


>1IIIIIHI«* 






















■a 


U»"»^ 














uun 



Fig. 9. — This chart shows that the amino-acid lysin is in- 
dispensable for growth. It is taken from Osborne and 
Mendel and shows the effect upon the growth of rats of add- 
ing lysin to and withdrawing it from the diet. 

In the first part of the upper curve the protein given is 
composed of equal parts of zein, a protein of corn, and 
gliadin, a protein of wheat. Zein is one of the poorest 
proteins and animals cannot be maintained upon it when 
it is the only protein in the food ; it contains no lysin ; glia- 
din has only a very small amount of lysin. In the second 
part of the upper curve, when all the protein is furnished 
by gliadin, a slight growth is observed; but when lysin is 
added an immediate growth begins which persists (dotted 
line) at a rate exceeding the normal increase (solid line). 

In the first part of the lower curve the protein is gliadin. 
When lysin is added there is a quick growth response which 
ceases when the lysin is omitted, is resumed by its addition 
and again stops when the lysin is withdrawn. 



94 FOOD, HEALTH AND GROWTH 

ing in themselves but have an important bear- 
ing upon the protein needs of children. They 
have determined exactly how much of certain 
proteins are required to support normal 
growth in rats; also, what is especially sig- 
nificant, to what extent the amount of these 
proteins in the diet can be reduced if their 
quality is improved by the addition of amino- 
acids in which they are known to be deficient ; 
thus how rapid growth can be secured with 
certain low grade proteins when these are 
reinforced by the addition of certain amino- 
acids (Figs. 9 and 10). 

Such experimentation is by its very nature 
quite impossible with children. Accordingly, 
about the only guide which we have to a 
knowledge of the total protein need for chil- 
dren is to be found in a study of the actual 
amounts of protein which are taken by nor- 
mal, healthy children in their customary diet. 
It is fully realised that the results of such 
a method of investigation as this are not con- 
clusive, but they are strongly suggestive. 
To begin with, let us consider the nursing 
2£k a Low i n f an t- The total protein intake of a normal 
in protein infant at the breast is very low. Up to the 
age of eight or nine months the amount sel- 
dom exceeds 12 grams daily; this is equivalent 
to only about 1.5 grams per kilo. This amount, 



PROTEIN REQUIREMENT 



95 



it is to be remembered, must supply not only 
the maintenance requirement but the need for 
growth, and that too during the most active 



JPROIEINS REINFORCED BY ADDITION OF AMMO-ACIDS 



IfiROWTH WITH CASEIN 



"SB 


r 




MO 


CYSTIME 




— . — 


240 


110 








•• 




/ 


HO 


flU 








^y 






12JI 


to 

40 


f 


r 


y 








60 

40 


/^ 


%>-^" 












— «MT«-J 











Fig. 10. — In this chart from Osborne and Mendel the 
upper curve shows the growth of rats whose food contained 
18 per cent casein. The first part of the lower curve shows 
the slower growth upon 9 per cent casein and the effect upon 
growth of adding and then withdrawing cystin. Casein 
protein is notably deficient in cystin and a larger amount of 
casein must be given to insure normal growth. 

period of growth in the life of the child, as 
the healthy child usually doubles his weight 
in the first five months. That this amount is 



96 FOOD, HEALTH AND GROWTH 

sufficient needs no argument. We find our 
best examples of good nutrition and growth 
in breast-fed infants. 

The reason why this small protein intake 
does supply the infant's entire requirements 
is to be found in the fact that the protein of 
woman's milk is certainly best adapted in 
its amino-acid composition for digestion 
and assimilation by the infant and for his 
growth. 
More is Now when cow's milk is substituted for 

when cow's woman's milk the conditions have materially 

Milk is . . J 

the Food changed. No longer will infants thrive satis- 
factorily on a protein intake of 10 or 12 grams 
daily. Experience has long taught us that 
the protein intake must now be considerably 
increased — doubled or even trebled. Infants 
from one to nine months of age, when fed on 
the usual modifications of cow 's milk, receive 
from 3 to 4 grams of protein per kilo. The 
great increase in protein requirement when 
cow's milk is substituted for woman's milk is 
probably due to the difference between the 
two milks in the amino-acids which their pro- 
teins contain. The protein of woman's milk 
is protein of a very high grade. It is com- 
posed of two-thirds lactalbumin; and lactal- 
bumin of all the proteins contains the high- 
est proportion of leucin, lysin and trypto- 



PROTEIN REQUIREMENT 97 

phan, amino-acids which are particularly im- 
portant for growth. Woman's milk contains 
about twice as much lactalbumin as does 
cow's milk. Casein, which forms about five- 
sixths of the protein of cow 's milk, is of com- 
paratively low grade as a growth protein, 
being notably deficient in cystin. In order to 
secure an adequate supply of this ammo-acid 
a greatly increased amount of casein must 
therefore be taken. 

This is well shown by Osborne and Men- 
del's experiments upon rats; they obtained 
good growth when the food contained 18 per 
cent of casein; poor growth with 9 per cent, 
but good growth with 9 per cent if cystin was 
added (Fig. 10). 

The failure of condensed milk as a food 
for infants has been ascribed to many causes ; Failures in 
by some, to its low fat and its relatively high low pro 
sugar content ; by others, to the effect of heat 
and age upon its vitamine content. With the 
facts just mentioned before us it now seems 
clear, that equally important — perhaps more 
important than either of these considerations 
— is its low protein. In the dilutions in which 
this is usually fed, the percentage of protein 
ranges from 1 to 1.4, which is only about the 
amount which an infant taking woman 's milk 
receives. 



teiiis 



98 FOOD, HEALTH AND GROWTH 

Again, in the early days of milk modifica- 
tion by the percentage method, it was thought 
that formulas from cow's milk in which the 
proportions of fat, sugar and protein were 
as nearly as possible the same as those found 
in woman's milk, would be the best substitute 
for it. But those who followed this plan in 
practice, were doomed to disappointment. 
The failures from the use of such formulas 
were variously explained ; by most, they were 
ascribed to the too high fat, and no doubt 
this was sometimes the case; but it now 
seems quite evident that an important error 
was the low protein in many of these formulas. 
With clinical experience it has become in- 
creasingly clear during the last few years, 
that the majority of infants will not thrive 
normally upon cow's milk unless they are 
given two or three times as much protein as 
is contained in woman's milk; also that the 
higher total protein of cow's milk is not the 
principal cause of its difficult digestion by the 
average infant. 

The proportion of vegetable proteins in 
the diet of infants is a very small one. 
cei^on??" Wither nursed or artificially fed the infant 
proSiis receives practically his entire protein supply 
in the form of animal protein, at least dur- 
ing the first six months of life. It is only 



PROTEIN REQUIREMENT 99 

when cereal additions are given, either as 
flour incorporated in the milk formula or as 
cereal given separately, that a portion, al- 
though at first a very small one, of the pro- 
tein given is of vegetable origin. 

When we come to consider the diet of chil- ^JJJJgf of 
dren past the period of infancy, we find that 2J5SJi for 
almost no attention has thus far been paid to ciiSrea 
its quantitative composition. There is, there- 
fore, very little material to be found in the 
literature concerning the actual daily amount 
of protein taken by older children. The few 
scattered data which have been published are 
for the most part incidental to researches on 
other subjects. Most of the authors, whose 
reports on the total calories taken by chil- 
dren were discussed in the previous lecture, 
have also reported the protein content of the 
diets taken. 

Gillett has compiled from eighteen authors, 
145 cases in which the amount of protein 
taken daily is given. These include most of 
the values for protein intake published in the 
literature up to 1917. Her summary shows 
that the average protein intake of all the 
groups was at least 2 grams per kilo, and the 
average of the younger children 3 grams per 
kilo. 

Miiller studied the diet of 32 children from 



100 FOOD, HEALTH AND GROWTH 

two to six years of age, inmates of an insti- 
tution, who took an average of 3.5 grams of 
proteins per kilo, daily. It should be borne 
in mind, however, that these children were 
much under weight. He thinks that the pro- 
tein need of children is proportionally very 
much greater than that of adults, and that 
children's no attempt should be made to reduce the pro- 
Greater ee tein intake to a minimum, lest growth be in- 
AdSits' terfered with and general nutrition im- 
paired. 

Gephart in his observations on the adoles- 
cent boys in St. Paul's School found the pro- 
tein intake to be very high at these ages. The 
average total daily protein was about 160 
grams; while the average protein per kilo, 
ranged from 2.6 to 3.8 grams. 

Camerer recommends over 4 grams of pro- 
tein per kilo, for the first year, from 3 to 4 
up to the eighth year, over 2 grams until the 
fourteenth year, diminishing to 1.7 grams at 
the end of the growth period. 

In the previous lecture were presented the 
values for total calories actually taken by 
over one hundred healthy children from one 
to seventeen years of age. In each of these 
cases it will be recalled we obtained complete 
diet records for a period of four days. These 
children were from intelligent, well-to-do 



PROTEIN REQUIREMENT 101 

families and may be assumed to be taking 
diets which are fairly representative of what 
children under such circumstances usually 
receive. 

A study of the amount of protein taken by TakSFby 
them should, therefore, give some idea of the American 
usual amount in the diet of healthy American clmdrett 
children. These results correspond quite 
closely with those just quoted, except that 



'Crro 
Zt2 



Grams Total Protein Taken Dally 































. 
























~~* 


Doy.i 
Girls 






















































































.. 


























• 










• 




' 








o~" 


-—«■■ 




-^ 





^v» 












• 


' 




• 


•y. 


W 
























,0» 


> 
* ■ 


\Z 




Z&& 


--o\ 


»o 


% 


• 


• 


















^^ 


b "^ 

> 




° 


° 


• 





































































ftars ' I Z 3 4 3 7 6 9 ID U 12 13 14 li 10 17 

Fig. 11. 

during the adolescent period of rapid growth 
the intake was the greater, and diminished 
after growth was slower and completed. 

Average total protein in 2nd and 3rd yrs. was 49 grams ; 4.0 per kilo 
" 6th and 7th " " 60 " 3.0 " " 

" " " « 11th and 12th " " 90 " 2.8 " " 
" 15th and 16th " " 130 M 2.3 " « 

" '* " ** 18th year " " 115 " 2.0 " " 

Our observations indicate that in the usual 



Exceptional 



102 FOOD, HEALTH AND GROWTH 

diet approximately 15 per cent of the total 
calories taken by children over one year old 
should be supplied by protein. 

In Figure 11 is given the total daily intake 
of protein of the individual children. The 
solid and dotted lines represent for boys and 
girls respectively the grams of protein which 
are equivalent to 15 per cent of the calories 
recommended. While the great majority of 
these cases fall reasonably near the average 
ESS? ^ nes there are some interesting exceptions 
which are worth noting. There are four 
young girls whose protein intake was very 
high. All were extremely active children, 
in excellent health, whose total food intake 
was very high. There were two large girls 
of thirteen and one-half years and fourteen 
years who took a very low amount of protein. 
But both had attained practically their full 
growth and for them really the only protein 
need was that for maintenance. 

There were three boys about ten years old 
with very high intake. The explanation 
in each case was excessive activity. A four- 
teen-year-old boy taking 210 grams of protein 
daily is an example of what is so often ob- 
served, that is, the very large amount of food 
frequently taken by an active, rapidly grow- 
ing boy at this age. It will be recalled that 



PROTEIN REQUIREMENT 103 

the average intake of the St. Paul's School 
boys was about 160 grams daily. 

The grams of protein per kilo, of body c^mpaJed 
weight taken by these children agree pretty wSJ?* 1 
well with the findings which have been pub- 
lished by others. Four-fifths of the children 
observed took between 2.2 and 4.4 grams pro- 
tein per kilo. The average was 4.4 per kilo, 
for the youngest group. The fourteen who 
took more than 4.4 grams per kilo, were 
mostly young and very active children, only 
three being as much as iive years of age. In 
general, the intake per kilo, tended to dimin- 
ish as age advanced. That for the oldest 
group, from fourteen to seventeen years, was 
between 2 and 2% grams per kilo. 

The values for some of the older children, 
particularly for girls between twelve and 
fifteen, are low; but it is probable that with 
more data the average of these years would 
be higher than is shown in the table owing 
to rapid growth at this age. 

These observations on normal children 
have also been analysed with respect to the 
proportion of animal and vegetable protein 
in the diets taken. 

Most of the children took over 60 per cent 
of their total protein in the form of animal 
protein, from milk, eggs, meat, etc. The 



Protein 



PROTEIN REQUIREMENT 105 

average was 66 per cent of the total protein 
from animal sources, and 34 per cent vege- ESSST 
table protein. Figure 12 shows graphically 2Z5ua irt 
the percentage division of the total protein in 
the diet of each child. The values are ar- 
ranged in order of age ; there was no constant 
variation noted. 

That there was found so little variation in 
the proportion of animal and vegetable pro- 
tein in the diet of the different children was 
a matter of much surprise. 

These observations indicate that healthy 
children in their usual diet take about 4.0 
grams of protein per kilo, at the age of one 
year, the amount diminishing to about 2.5 
grams per kilo, or 0.25 per cent of body 
weight at six years of age and remaining 
at about this value or slightly below it until 
the end of growth, and that of this total prac- 
tically two-thirds is animal protein. This 
quantity of protein may perhaps be regarded 
at present as the optimum and may therefore 
be recommended as a suitable intake for the 
growing child. 

When we come to consider how much of this 
total should be animal protein we have very 
little knowledge to guide us. It is quite pos- 
sible that children might do well if less than 
two-thirds of this was animal protein. How- 



106 



FOOD, HEALTH AND GROWTH 



Vegetable 
Proteins of 
Lower 
Grade and 
More Must 
be Given 



Summary 



ever, from what is known of the growth prop- 
erties of the vegetable proteins as a class it 
is evident that a much larger amount of vege- 
table protein would be required if the amino- 
acids necessary for normal growth were sup- 
plied. 

Vegetable protein cannot replace animal 
protein gram for gram. Accordingly, if one 
is to give a larger proportion of vegetable 
protein than the usual one-third of the total 
requirement, it seems clear that the total pro- 
tein intake must be considerably increased. 
In our common vegetable foods protein is 
always associated with carbohydrate and 
when the amount of vegetable protein given 
is increased very much above the average, it 
should be realised that the amount of carbo- 
hydrate is necessarily increased also, and 
this may be undesirable and may be a cause 
of disturbance to digestion. 

In conclusion it is evident that no estimate 
of the amount of protein required for the 
proper nutrition of children can be made 
without taking into account the kind of pro- 
tein given, since the amino-acid content of 
different proteins varies so considerably; 
also that in estimating the protein needs of 
the child not only must the need for mainte- 
nance be supplied, as with the adult, but also 



FAT REQUIREMENT 107 

a liberal amount of protein must be allowed 
for growth. 

The fact that the small amount of protein 
taken by nursing infants is adequate is due 
to the superior amino-acid composition of the 
proteins of woman's milk. 

When cow's milk is substituted for woman's 
milk the amount of protein allowed should be 
increased — doubled or trebled. 

Vegetable proteins as a class are of a dis- 
tinctly lower grade than animal proteins, and 
while they may be adequate for maintenance, 
with our present knowledge, it is hazardous 
to depend upon them for growth. 

II. Fat Requirement 

The amount of fat which is required in the 
diet during growth has not yet been, and 
cannot be established until the exact role 
of fat has been determined. Until quite re- 
cently it has been generally believed that 
fat did not play any specific part in nutrition, 
but, like carbohydrate, served as a source of 
energy and as a sparer of protein. Because 
of this belief very little attention has been 
given to the amount of fat which is desirable 
in the diet, except in the case of infants. Ke- 
cent investigations, however, have shown that 
fat is of greater importance than was for- 



108 FOOD, HEALTH AND GROWTH 

merly believed, and that it has specific func- 
tions in nutrition quite apart from those 
which it shares with the carbohydrates. It 
has been shown that during growth fat is 
5"£Jj ons especially important. There are now recog- 
nised to be several reasons for regarding fat 
as a necessary constituent of the diet of chil- 
dren. 

Fat is the carrier of the fat-soluble vita- 
mine which has been proven to be essential 
for health and normal growth. A fuller dis- 
cussion of this will be taken up later with the 
general subject of accessory food substances. 
How much of this vitamine should be pro- 
vided for the child is not yet known. 

From the evidence which has been obtained 
it would seem that the amount of fat needed 
for this purpose is comparatively small; but 
in order to insure normal growth it is prob- 
ably wiser to supply in the diet a generous 
amount of such fats as are known to contain 
this substance. 

Among the usual foodstuffs the richest 
sources are milk fat, egg yolk and certain ani- 
mal organs — liver, kidney, etc. It is es- 
pecially abundant in cod liver oil. This vita- 
mine is also found in the green leaves used 
soiuS*" as vegetables, but since the young child can 
viXm£e a take only a comparatively small quantity of 



FAT REQUIREMENT 109 

these in the diet it is not wise to depend upon 
them as a source of this vitamine to any great 
extent. 

Since the function of the vitamine s has 
been appreciated there has been a growing 
tendency on the part of those particularly 
interested in them to regard the fat of the 
diet of special importance only as a carrier 
of vitamine A. 

These investigators seem inclined to attrib- 
ute all the bad effects of a diet low in fat 
to a vitamine deficiency. The fact that such 
a diet predisposes to rickets and possibly to 
oedema, that it increases the susceptibility to 
infection and retards growth, is explained by 
them in this way. Their contention is that 
if sufficient vitamine A is supplied in a diet 
which is fat-free but otherwise adequate, the 
conditions just mentioned will not develop. 

Most of the conclusions regarding the func- ^^Jf n ?*" 
tions of vitamines have been drawn from ex- 
periments upon small laboratory animals, 
chiefly rats. Mendel and Osborne have re- 
cently published the results of experiments 
continued for from four to eight months in 
which they obtained what they considered 
normal growth in rats on a diet in which the 
fat was extremely low, amounting to but 1/20 
of one per cent of the total food ; but the diet 



110 FOOD, HEALTH AND GROWTH 

included the necessary amount of the vita- 
mine A, derived in this case from dried al- 
falfa leaves. They conclude that "if true 
fats are essential for nutrition during growth 
the minimum necessary must be exceedingly 
small. ' ' 

To apply too dogmatically to human beings 
the results of experiments upon small ani- 
mals which are of a species so different, 
seems open to some question. The natural 
diet of the rat is very unlike that of human be- 
ings and consequently its digestive processes 
may not be entirely comparable. Hence, it 
is conceivable that fat may have functions in 
human nutrition which may not be required of 
it in the nutrition of the rat, quite apart from 
that as a purveyor of vitamine A. 
Von Groer of Vienna has observed the ef- 
i?t-Free 0n ^ ec ^ s °^ a ^^ Practically fat-free upon two 
Diet infants from birth. The food given was sepa- 

rated cow's milk containing only 0.01 per cent 
of fat, with enough cane sugar added to give 
a total carbohydrate content of about 8.5 per 
cent. This diet was not only practically de- 
void of fat, but also extremely low in vita- 
mine A and very high in carbohydrate. Both 
infants gained in weight with fair regularity 
for six months. But after six months the 
gain ceased. Both developed rickets and were 



FAT REQUIREMENT 111 

very susceptible to infection. The conclu- 
sions reached by von Groer is that for at 
least the first six months of life infants can 
be successfully nourished on a diet which is 
practically fat-free provided the calories 
needed are supplied by sugar. His reported 
results hardly bear out this contention. 

Another function of fat which is questioned 
by some is its influence on mineral metabo- 
lism. This has been much debated and the 
subject cannot yet be regarded as entirely 
settled. Many laboratory observations have 
been made to ascertain the influence of the 
fat intake upon the mineral metabolism of 
infants and very young children. 

Unfortunately the results thus far have 
been conflicting and final conclusions have 
not yet been reached. Although some investi- 
gators are convinced that there is no rela- 
tion between the fat intake and the mineral 
metabolism in general, we feel certain that 
in the case of calcium metabolism at least a 
very definite relation exists. The work on rat and 

J Absorption 

calcium metabolism done in the Babies ' Hos- of calcium 
pital laboratory indicates that the best cal- 
cium absorption takes place when the fat in 
the diet bears a certain relation to the cal- 
cium and when the intake of both is liberal. 
The results indicate that the daily fat intake 

\ 



112 FOOD, HEALTH AND GROWTH 

of children from two to four years of age 
should not be less than 3.0 grams per kilo, 
to insure proper absorption of calcium. This 
requirement seems to diminish up to six years 
of age to about 2.0 grams per kilo., but is 
probably maintained at about this figure 
throughout the remainder of childhood. 
Since adequate absorption of calcium is nec- 
essary for bone growth, this need seems a 
very important one. The observations also 
show that for the purpose of calcium absorp- 
tion a vegetable fat will serve quite as well as 
an animal fat. 

Some authors have recently taken the 
ground that the fat of the diet has an impor- 
tant influence on the metabolism of protein. 

It is contended that the amount of fat in 
the diet should at least be equal to the amount 
of the protein. Thus fat should not be re- 
garded as supplementary to the dietary re- 
quirement but an integral part of it. It is 
certainly a very significant fact that in 
woman 's milk the fat exists in a considerably 
greater amount than the protein while in 
cow's milk they are nearly equal. 

It is generally accepted that the lack of fat 
in the diet increases susceptibility to infec- 
tions, especially to tuberculosis. Although 
children may apparently do very well for a 



FAT REQUIREMENT 113 

time on a low fat or a fat-free diet, the com- 
plete elimination of fat from the diet or even 
its reduction to insignificant proportions, as 
recently proposed by Pirquet, seems a hazard- 
ous experiment. 

Furthermore, it seems clear that a reason- 
able amount of fat in the diet is useful in 
maintaining normal chemical and bacterio- 
logical conditions in the intestine. This is 
indicated by observations on the character destines 
and composition of the stools. When fats are 
excluded or greatly reduced in the diet there 
is inevitably a great increase in the carbo- 
hydrates. Among many stools studied we 
have not found any which would be generally 
regarded as typically normal in character 
and consistency under these conditions. With 
children whose digestion is normal the change 
does not take place at once ; but after a period 
usually of a week or ten days the stools gen- 
erally become softer, more of a " mushy' ' con- 
sistency with greatly increased acidity and 
after a short time mucus usually appears. 
There is also a change in the intestinal flora. 
The addition of fat to the food very quickly 
brings about a decided improvement in the 
appearance of the stool. 

Only a small part, usually about 5 per cent, 
of the ingested fat is not absorbed; but we 



114 FOOD, HEALTH AND GROWTH 

believe that this amount has, as Hutchison 
has recently suggested, a special function to 
perform, and is not to be regarded as a pure 
excretion. 
Excreted The fat excreted is largely in the form of 

Largely as ° ^ 

soaps soaps which give solid consistency to the stool. 

When the normal amount of soap is present 
there is no excessive acidity. The action of 
soaps to a certain degree seems to be to pro- 
tect the mucous membrane of the intestine 
from injury by the products of excessive fer- 
mentation of the carbohydrates. The acidity 
of the stool is to a great extent dependent 
upon the relative proportions of fat and car- 
bohydrate in the diet. 

Aside from these reasons for regarding the 
fat per se as an important constituent of the 
diet of the child, it must not be forgotten that 
as a source of energy fat provides more than 
twice as many calories per gram as does 
either protein or carbohydrate. 

It seems, therefore, quite clear that a cer- 
tain amount of fat is desirable and probably 
essential for the best nutrition of the growing 
child. The quantity needed, however, is diffi- 
cult to determine. At the present time it can 
only be conjectured. Many authorities think 
that the diet naturally chosen is an indication 
of a physiological need. That fat is an impor- 



PAT REQUIREMENT 115 

tant component of the diet of the infant is 
shown by the composition of woman's milk. 
The normal amount of fat in woman's milk Amount 
averages between 3 and 4 per cent; and Nursing 

° r Infants 

this furnishes approximately half the total 
calories in the diet of the nursing infant. 
This cannot be without significance. It seems 
hardly conceivable that so much fat would 
be supplied by nature if the only specific pur- 
pose of the fat were to furnish vitamine A. 
The nursing infant usually receives during 
the early weeks as much as 20 grams of fat 
daily. This total increases by the seventh 
month up to an average of 40 grams daily. 
This represents about 4 grams per kilo, of 
body weight. Nothing is more characteris- 
tic in the nutrition of the nursing infant than 
the facility with which this large amount of 
fat is taken and utilised. Nothing certainly 
contributes so much to firm tissues and the 
appearance of perfect health as this. 

Fat is also generously provided by nature 
for the young of all mammals. All the ani- 
mal milks contain a large amount of fat, many 
of them in greater proportion even than is 
found in woman's milk. It is also noteworthy 
that in nearly all milks the amounts of fat 
and protein run almost parallel. 

The infant fed on modifications of cow's 



116 FOOD, HEALTH AND GROWTH 

SSmlom 11 m ^k seldom receives as much as does the 
cow^ mik nursing infant. This is mainly because the di- 
gestion of the fat of cow's milk is somewhat 
difficult for most infants and it must there- 
fore be given in smaller amounts and in- 
creased cautiously. The fat intake must be 
varied with the individual reaction of the in- 
fant to the fat of cow's milk. A few infants 
can take more than this with advantage; 
many must be given less. 

Although there are in the literature many 
statements regarding the amount of fat 
recommended for children after infancy there 
are but few records of the amounts of fat 
taken by individual children, and few ob- 
servations as to the effects of either a very 
high or a very low fat intake. The amount 
of fat taken by over one hundred normal 
children studied by us may perhaps be re- 
garded as typical of that usually taken by 
healthy children. Over three-fourths of these 
children took between 2 and 4 grams per 
Amount of kilo, daily. The average for both sexes dur- 
bToidS 11 ing the early years was a little over 3 grams 
per kilo, of body weight. As age advanced 
there was a gradual reduction in the grams 
of fat per kilo. Most of the instances of very 
high fat intake were in children of extreme 
activity whose total food intake was high. 



FAT REQUIREMENT 117 

Two boys in their fifteenth and sixteenth 
years, respectively, took over 150 grams of 
fat daily. There is a practically steady in- 
crease with age in the average total fat in- 
take, the maximum being reached, as would 
be expected, during the fifteenth and six- 
teenth years. 

Muller gives the average fat intake of 
thirty-two children from two to six years of 
age as 3.45 grams per kilo. This is in accord 
with our findings for corresponding ages. 

Most of the observations reported by other low Fat 
German authors show T lower values. Those GelSu? 7 
of Camerer, who has been widely accepted 
as an authority, are especially low, most of 
his values being less than 1.5 grams per kilo. 

Among the German authors who have pro- 
posed a scheme of feeding in w T hich exact 
quantities of the food constituents are given, 
Steffen is about the only one who recom- 
mends a generous fat intake. Pirquet has 
taken the position that fat is not a funda- 
mentally essential article of diet and that 
it can be replaced by carbohydrate without 
harm to the organism. 

In Gephart's report upon the diet of the 
boys of St. PauPs School he states that they 
took about 200 grams of fat daily. 

The younger group, averaging thirteen] 



118 



FOOD, HEALTH AND GROWTH 



Amount 
Taken, by 
Adolescent 
Boys 



Symptoms 
from Too 
Much Fat 



and one-half years of age, took an average of 
4.5 grams of fat per kilo., and the older group, 
averaging sixteen and one-half years, took 
3.4 grams of fat per kilo. All these values 
are much higher than has been thought normal. 

The average adult diet based on many ob- 
servations contains only about half the 
amount of fat taken by these boys. The fact 
that the fat intake of healthy boys was 
so high is undoubtedly significant. This 
large amount of fat apparently had no dele- 
terious effect. On the contrary the boys 
thrived upon it and it seemed to represent a 
physiological need. It confirms our belief 
that the fat requirements are especially large 
during the periods of most active growth (in- 
fancy and adolescence) and that at the latter 
period they exceed adult requirements. 

There is a disposition among certain clini- 
cians to ascribe most of the digestive disturb- 
ances in children taking a mixed diet to the 
fat in the food, particularly the fat of cow's 
milk. It is undoubtedly true that under cer- 
tain conditions a very high intake of fat, par- 
ticularly if accompanied by a reduction in 
the carbohydrate intake, may bring about 
quite serious disturbances of digestion. Ger- 
man writers describe it under the name Milch- 
nahrschaden. The characteristic symptoms 



FAT REQUIREMENT 119 

in such cases are familiar : the coated tongue, 
bad breath, general malaise, constipation, 
with large gray stools containing a high pro- 
portion of fat, and occasionally severe and 
prolonged attacks of vomiting. 

These symptoms are regularly relieved by 
greatly reducing fats and increasing carbo- 
hydrates in the diet. 

There are many other cases, however, 
when fat is blamed, when the real cause is 
simply too much food; as when children of 
limited activity are given a quart or more of 
milk, often rich milk too, daily, in addition An un- 
to a liberal diet of solid food. It is important eS 1106 
before attributing the trouble to the fat to 
consider the diet as a whole, both as to the 
total amount of food taken and the relative 
amounts of fat and carbohydrate which the 
diet contains. There is evidence that when 
the diet is properly balanced, that is, con- 
tains the fat, protein and carbohydrate in 
the right relation to each other, a child can di- 
gest very much larger amounts of fat than 
when the diet is unbalanced. 

While it may not yet be proven that a large 
amount of fat is essential in the diet during 
growth, there are so many reasons for a lib- 
eral allowance of fat, and so little evidence f/fattoa 
that this is harmful, that it does not seem unSSae 



120 



FOOD, HEALTH AND GBOWTH 



Amount 
Kecom- 

meuded 



wise, with our present knowledge, to en- 
deavour to reduce the fat in the diet to a mini- 
mum, or even to give much less than the 
amount which healthy children usually take 
at the present time; while to exclude it en- 
tirely from the diet seems quite unjustifiable. 
From the foregoing considerations it seems 
reasonable to allow growing children in the 
diet at least as much fat as protein. On this 
basis, the proper amount seems to be nearly 
4.0 grams per kilo, daily at one year, dimin- 
ishing to about 3.0 grams or 0.3 per cent of 
the body weight at six years and thereafter. 
It seems probable that the child's nutrition is 
best assured by not permitting the fat allow- 
ance to fall much below this value during 
the remainder of the growth period. 



Functions 
of Carbohy- 
drate in 
Diet 



III. Carbohydrate Requirement 

The carbohydrates probably have no spe- 
cific function to perform in the diet of the 
growing child but are nevertheless very es- 
sential components. They serve mainly as a 
source of energy, supplying the necessary 
calories not furnished by fat and protein. In 
many respects fats and carbohydrates in the 
diet are interchangeable, so that in conditions 
of marked fat intolerance carbohydrates may 
entirely replace fats for a considerable 



CARBOHYDRATE REQUIREMENT 121 

period. However, carbohydrates accomplish 
other purposes. They undoubtedly play an 
important part in the metabolism of fat; 
without the addition of carbohydrate to the 
diet it is generally believed that complete me- 
tabolism of fat is impossible. In its capacity 
to spare protein carbohydrate is even su- 
perior to fat. These functions of carbohy- 
drate are well known and need not be dis- 
cussed. 

When digestion is normal, carbohydrate is 
almost if not quite completely utilised in the 
body. What is not immediately used for en- 
ergy is stored as glycogen to be later used 
for energy, or it is converted into fat and 
added as fat to the tissues of the body. The 
excess is usually broken down by fermenta- 
tion in ftie intestines. While of all the food 
constituents it is most easily and most com- 
pletely digested under normal conditions, 
when digestion is disturbed it is the one 
which breaks down readily to form irritating 
products in the intestine. 

The carbohydrates are altogether the most 
economical food we possess from both a com- our Most 
mercial and a physiological point of view, rood 
They can be produced more cheaply ; because 
not perishable they can be transported and 
stored with less expense and less likelihood 



122 FOOD, HEALTH AND GROWTH 

of deterioration. They are consequently 
much less expensive than fat and protein 
foods. 1 They are economical physiologically 
because of their almost complete utilisation 
under normal conditions. It is not surpris- 
ing therefore that carbohydrate has come to 
form the greatest part of the diet at all peri- 
ods of life except early infancy. 



1 Calories Purchasable for Ten Cents at a Small New 
York Eetail Store on a Given Date 



Articles 


Eetail Price 


Number op 
Calories 


Carbohydrate foods 






Sugar, granulated 


6 cents per pound 


3100 


Karo Corn Syrup 


20 cents per 2.5 lb. can 


1970 


Oatmeal 


12 cents per 20 oz. pkg. 


1930 


Eice 


12 cents per pound 


1360 


Bread 


9 cents per 15 oz. loaf 


1270 


Cream of Wheat 


30 cents per 28 oz. pkg. 


980 


Potato 


5 cents per pound 


770 


Jam 


20 cents per lb. jar 


530 


Fat foods 






Butter 


49 cents per pound 


740 


Olive oil 


65 cents per pint 


600 


Cream— Sheffield X 






(includes some pro- 






tein and sugar) 


32 cents per half pint 


240 


Protein foods (include 






some fat) 






Cheese, American 


35 cents per pound 


590 


Lean beef, round 


44 cents per pound 


200 


Eggs, fresh brown 


60 cents per dozen 


180 


Mixed food 






Milk— Sheffield, 






Grade A 


18 cents per quart 


355 



CARBOHYDRATE REQUIREMENT 123 

But even at this time the lactose of %£*£* 
woman's milk supplies nearly one-half of its SrSSi* 1 
caloric value. The nursing infant takes daily 
about 30 grams of lactose during the early 
weeks and usually as much as 80 grams dur- 
ing the latter part of the nursing period. 
Young infants taking modifications of cow's 
milk often receive considerably more carbo- 
hydrate than do nursing infants. This is 
chiefly because it is impossible to give them 
the amount of fat which the nursing infant 
usually receives. 

The nursing infant receives carbohydrate 
entirely in one form — lactose. The infant 
fed on cow's milk may take entirely lactose or 
partly lactose and partly saccharose, mal- 
tose, dextrin or starch or various combina- 
tions of these. It is not usual for any large 
proportion of the carbohydrate to be given 
as starch until after infancy, when the child 
takes a mixed diet. In a mixed diet after 
one year at least one-half of the carbohy- 
drate is usually in the form of starch, the 
rest being various sugars — milk sugar, cane 
sugar and fruit sugar and occasionally some 
dextrin or maltose. 

The amount of carbohydrate taken by chil- 
dren over one year of age varies consider- 
ably according to the theories of the parent 



124 



FOOD, HEALTH AND GROWTH 



Disposition 
to Feed 
Too Much 
Carbohy- 
drate 



or physician and even more to the habit or 
taste of the child. 

On account of the conditions mentioned 
there is at present a growing tendency to al- 
low carbohydrate foods to form a larger and 
larger proportion of the diet. There are some 
children the largest item of whose diet is 
bread; with others it is potato or cereal. 
There is also a steady increase in the con- 
sumption of sugar and sweets by all classes. 
One hundred years ago the per capita con- 
sumption of sugar in the United States was 
eight pounds; last year it was 84 pounds. 
This is either taken as sugar in or upon food 
or in the form of syrup, jelly, jam, candy, etc. 
An official of one of the large five and ten 
cent store corporations has made the state- 
ment that their annual sales of candy ex- 
ceeded 60,000 tons ! 

The carbohydrate intake which was calcu- 
lated of over one hundred healthy children 
studied by us 1 illustrates the wide variation 
in the usual diet of normal healthy children. 
Since the ages of the children varied from 
one to eighteen years the variation in intake 
is best shown per kilo, of body weight. The 

1 The details of these observations showing intake of the 
individual eases have been published elsewhere — see Ameri- 
can Journal Diseases of Children, July, 1922. 



CARBOHYDRATE REQUIREMENT 125 

usual range was from 8 to 12 grams per kilo. ; 
the average of all the cases being about 10 
grams. There were more instances of very 
high than of very low intake. In a number 
of cases the children took over 15 grams per 
kilo. 

The actual amounts of carbohydrate taken 
by the different children were also interest- 
ing. There were few instances of very low 
intake; there were, however, several exceed- 
ingly high ones. One girl, between eight and 
nine years of age, took 464 grams of carbo- 
hydrate daily. One boy of nine took 560 
grams; one of ten took 488 grams; and one 
of fourteen took 683 grams daily. The total 
daily intake increased with fair regularity 
with the years. The boys averaged more 
than the girls except during the earliest 
years. 

The observations reported in the literature, 
in which the carbohydrate intake of children 
after infancy was ascertained, showed varia- 
tions quite as wide as those in our own cases. 
In general, the amount of carbohydrate per 
kilo, of body weight reported taken by young 
children is higher than that taken by older 
children. 

Gephart found that the amount of carbo- 
hydrate taken by the boys at St. Paul's 



126 FOOD, HEALTH AND GROWTH 

School was much in excess of the average 
adult consumption and averaged over 600 
grams daily. Part of the large intake of these 
boys is to be explained by sweets they con- 
sumed. The carbohydrate intake repre- 
sented an average of 13.7 grams per kilo, for 
the youngest group about thirteen years old, 
and 10 grams for the older group averaging 
sixteen years, 
what oider How much this represents can best be 
AdStsTake judged by comparison with the usual adult 
dietary which allows 400 to 550 grams daily 
and which is from 5 to 8 grams per kilo, of 
body weight. Murlin found that the men 
in the U. S. Army training camps took an 
average of 545 grams of carbohydrate daily, 
or about 8 grams per kilo, of body weight. 

From the data obtained concerning the diet 
taken by the group of normal children studied 
it was possible to calculate very approxi- 
mately the amounts of sugar and starch 
which made up the total carbohydrate. 

The values obtained are only approximate, 
since the relative amounts of sugar and 
starch used in cooking various articles of 
food such as cake, puddings, etc., could in 
most cases be only estimated from a knowl- 
edge of common recipes. It is believed how- 
ever that these estimates are fairly accurate. 



128 



FOOD, HEALTH AND GROWTH 



About Half 
tie Carbo- 
hydrate 
Taken is 
Sugar 



It was quite surprising to find that the av- 
erage of all the cases, regardless of age, 
showed that 51 per cent of the carbohydrate 
taken was sugar of some form. The range 
of sugar taken was naturally wide, but in 
over two-thirds of the cases it was between 
40 and 60 per cent of the total carbohydrate. 

In the accompanying chart (Fig. 13) the 
proportions of starch and sugar are given, 
arranged according to age, the heavy verti- 
cal lines dividing the years. This shows com- 
paratively little variation with the different 
children in the proportion of the carbohy- 
drate which was taken as starch and sugar. 

It is apparently usual in a mixed diet of 
healthy American children to give uncon- 
sciously practically equal amounts of starch 
and sugar. It should be noted that sugar 
here includes not only the saccharose used 
in cooking or on cereal, candy, etc., but also 
the fruit sugars and the lactose of the milk 
which was taken separately or which was 
used in cooking. 

It was also possible to estimate the pro- 
portions of different sugars constituting the 
sugar intake of the different children. There 
was little regularity seen in the proportions 
of different sugars taken ; in the early years 
lactose supplied the largest proportion of 



CARBOHYDRATE REQUIREMENT 129 

the sugar. The proportion of saccharose 
increased with advancing years. There was 
a steady increase with the years up to the 
eleventh year; during adolescence it was 
about ten times as much as the average taken 
by children under five years of age. 

It is surprising to note how much of the 
sugar intake was supplied by fruits. This 
was largely fructose, but some of it was sac- 
charose and it included also in some instances, 
as in the banana, a small amount of starch. 
Other sugars played a very insignificant part 
in the sugar intake. 

Because of the ease with which carbohy- 
drate is utilised in the body and because of objections 

J to Too 

its lower cost, there is a constant tendency JJgJ^JgJ 
to allow carbohydrate food to form an exces- to Diet 
sive proportion of the diet. There are sev- 
eral disadvantages in this procedure. If the 
proper number of calories is taken, a very 
high proportion of carbohydrate means a low 
proportion of either fat or protein or both. ; 
Hence there always exists the danger of low- 
ering the amount of fat or protein below that 
which is necessary for normal nutrition. In 
such instances there may result an excessive 
retention of water in the tissues of the body. 
A diet excessive in carbohydrate often 
leads also to an abnormal deposition of fat in 



130 



FOOD, HEALTH AND GROWTH 



Pigs Fed on 

Condensed 

Milk 



the body. Such a condition is more frequently 
seen in infancy where the food is condensed 
milk or some one of the proprietary infant 
foods which are largely composed of carbo- 
hydrates. The tissues of such infants are 
high in fat and water but low in muscle de- 
velopment. If acute disturbance of diges- 
tion or infection takes place this unnatural 
weight is rapidly lost. The children have but 
feeble resistance and they often succumb 
quickly. 

A similar condition was produced experi- 
mentally in pigs by Washburn and Jones. 
They found that young pigs fed upon sweet- 
ened condensed milk put on an excessive 



Comparison of Growth in Seven Weeks of Sex Pigs on 
Condensed Milk with Six Pigs on Whole Milk 



Feeding 


.So. 

5s£ 


'3 

"53 
£.5 


c 

V 

'- - 

iD.g 


ft 


GO 

m 


Whole milk 


1370 
1270 


11.35 

8.10 


9.2 
23.65 


15.61 
10.92 


362 


Sweetened condensed milk 


243 



Whole milk contained fat 3.3; sugar 5.2; protein 3.6 per 
cent. 

Sweetened condensed milk contained fat 1.6; sugar 9.8; 
protein 1.6 per cent. 



amount of fat. The protein increase in their 
bodies was, however, much below normal and 



CARBOHYDRATE REQUIREMENT 131 

the bone development was defective, the 
bones being only two-thirds as strong as when 
whole milk was fed. The table gives a sum- 
mary of some of their findings. 

There is a growing belief that the large and 
constantly increasing proportion of carbo- 
hydrate in the diet of civilised races has a 
very important relation to the prevalence 
of dental caries. The observation has been 
made by several investigators that Arctic £j^ ive 
peoples whose diet is almost entirely fat and JJdDlSai 
protein with but very little carbohydrate, Cariea 
rarely suffer from dental caries. Whether 
this tendency is due to the excess of carbohy- 
drate or to the consequent reduction of other 
constituents of the diet — fat, protein, mineral 
salts or vitamines — has not yet been estab- 
lished. 

Of more importance probably is the effect 
on digestion of a diet in which the proportion 
of carbohydrate is excessive. If a large 
amount of carbohydrate, especially if in the Produc 
form of sugar, is taken into the digestive JJJSeiF 
tract at one time, it is often impossible for Di g estion 
absorption to proceed at a rate rapid enough 
to take care of this amount, and the conse- 
quence is excessive fermentation due to bac- 
terial action; this leads to the formation of 
gases and irritating organic acids. The re- 



132 FOOD, HEALTH AND GROWTH 

suit may be loose, irritating, acid stools. 
Sometimes there may be serious diarrhoea. 
If the excess in carbohydrate is in the form 
of starchy food there may be constipation 
with abdominal distention, flatulence and 
colic. Usually these disorders of digestion 
are acute and not very severe, yielding 
quickly to proper dietetic treatment. When, 
however, they are frequently repeated or 
are prolonged because the dietetic error is 
not corrected, they may lead to serious 
chronic disturbances with marked loss in 
weight. 

It has been shown that a fairly definite 

amount of protein must be included in the 

diet of a growing child; it seems altogether 

probable that it is best to include at least an 

equal amount of fat. When these have been 

provided, the remainder of the total calories 

needed at any age will determine the amount 

Allowance of carbohydrate. On this basis it appears 

age ciuid reasonable to allow as an average diet about 

12 grams of carbohydrate per kilo, at one 

year decreasing to between 9 and 10 grams 

per kilo, at six years and maintaining about 

this value throughout the remainder of the 

growth period. 

If the total caloric need is increased much 



CARBOHYDRATE REQUIREMENT 133 

above the average because of unusual muscu- 
lar activity, carbohydrate may supply the 
entire amount of extra energy, since an in- 
crease in muscular activity does not increase 
the protein need above the normal. 

Carbohydrate is a desirable and probably Summaf y 
an essential component of the diet, although 
it does not have any specific function in 
nutrition. It forms the largest part of the 
diet at all periods of life and furnishes the 
calories needed in the diet which are not 
supplied by the requisite amounts of fat and 
protein. 

The carbohydrate intake of over one hun- 
dred healthy children from one to eighteen 
years of age, studied by us, averaged 10 
grams per kilo. Of this 51 per cent were 
sugars, including lactose, saccharose, and 
fructose, and 49 per cent was starch. 

Carbohydrate is more economical than fat 
or protein, both physiologically and com- 
mercially. Because of this latter advantage 
there is a growing tendency to increase the 
proportion of carbohydrate in the diet beyond 
the amount which is desirable. 

When a very large proportion of the food 
is in the form of carbohydrate the intake of 
fat or of protein or of both is likely to be less 



134 FOOD, HEALTH AND GROWTH 

than the normal nutritive need of the 
body. 

A diet excessive in carbohydrate leads to 
an abnormal deposition of fat without a cor- 
responding increase in muscle development. 
Children taking such a diet have feeble resist- 
ance to infection. 

There is much evidence that a relation 
exists between the high proportion of carbo- 
hydrate in the modern diet and the preva- 
lence of dental caries. 

Digestive disturbances, chiefly intestinal, 
may be produced when the carbohydrate in 
the diet is excessive. There may result in- 
creased fermentation with loose acid stools 
or constipation with flatulence and abdominal 
distention. When long continued, these dis- 
turbances are very difficult to control. 

It seems rational to allow in the diet of the 
child of average activity about 12 grams of 
carbohydrate per kilo, of body weight at one 
year, decreasing the amount to about 10 
grams per kilo., or 1 per cent of the body 
weight, at six years and maintaining it at this 
value through the remainder of the growth 
period. 

If because of unusual activity the total 
caloric requirement is increased this increase 
can be supplied by carbohydrates alone. 



MINERAL SALTS 135 



IV. Mineral Salts 



Specially 



A discussion of the mineral salts need not 
be entered into at length; yet a few words 
seem necessary. While not sources of energy 
they are just as necessary constituents of the 
diet as are fat, protein and carbohydrate. 
They are in fact indispensable to growth and 
normal nutrition. 

None of the normal physiological functions 
of the body, such as secretion, excretion 
or osmosis, can go on without them. These 
facts have all been well known for many 
years. 

Their special importance in childhood re- 
lates to the fact that at this period they have SuSE? 11 * 
an added function in promoting growth. Grovnil 
This relates obviously to the growth of the 
skeleton. But there is evidence that they 
have other functions in growth not so well 
understood. The effect upon the develop- 
ment of bones of a diet deficient in mineral 
salts is well known. It is very marked but 
occurs slowly. However, the degree to which 
growth and gain in weight are influenced by 
the mineral salts in the diet is not so gener- 
ally appreciated. How great this is and how 
quickly the effects are manifested are indi- 
cated by the growth curves of rats in the ex- 



136 



FOOD, HEALTH AND GROWTH 



periments of Osborne and Mendel (Fig. 14). 
The first curve shows slow growth with a diet 
low in calcium, a sharp rise when calcium in 
adequate amount is supplied, a cessation of 



GROWTH WITH NETS DEFICIENT IN MINERAL SALTS 



••••MDIET low in calcium 

■BBBD1ET AMPLE IH CALCIUM 



mmnmooiDlET LOW IH PHOSPHORUS 
bhbeuDIET AMPLE W PHOSPHORUS 




GRAMS 



Fig. 14. 



growth when this is reduced, and a sharp rise 
when it is again added. The second curve 
shows the same thing with reference to phos- 
phorus. The diet was essentially the same 
throughout except in its salt content. 



MINERAL SALTS 137 

Phosphorus and in fact most of the inor- 
ganic salts are so abundantly supplied in all 
our foods that there is little likelihood of a 
deficiency in any of them when the usual diet 
is taken. There are, however, two which may 
be deficient and whose importance is so great 
that the lack is evident in the nutrition, viz., 
iron and calcium. 

The very low iron content of cow's milk 
constitutes one of its important deficiencies 
as a food for infants and very young children. 
If the diet consists largely or almost ex- 
clusively of miJk for a prolonged period there 
is frequently seen a degree of anaemia which 
may be very disturbing. This most often oc- Low'm 3 ?^ 
curs when a child because of the indulgence 
of parents or nurses has not been weaned 
from a bottle at two or sometimes at three 
years, and in consequence persistently re- 
fuses all other food than milk from the bottle. 
This is perhaps the most important reason 
for beginning the use of other foods than 
milk at an earlier period than was formerly 
the practice. If a child at eleven or twelve 
months is taking fruit juice, beef juice, egg 
and some pureed vegetable, the supply of 
iron needed is provided. 

Our chief sources of calcium are milk, eggs 
and vegetables, especially the green vege- 



Milk most 
Important 



138 FOOD, HEALTH AND GROWTH 

tables. The quantity of green vegetable 
which can be given to a young child is 
small and the number of eggs which can 
be allowed in the diet is limited. Besides, 
the amount of calcium in vegetables is not 
large. A good helping of spinach, which 
is the richest of our vegetables in this min- 
eral, contains only as much calcium as does 
one ounce of milk, and one egg has but a 
caKn 0f little more than this amount. 

The importance of milk as a source of cal- 
cium becomes at once apparent and it matters 
little whether it is milk which is drunk or 
milk used in the preparation of other food; 
or whether milk is raw, pasteurised, skimmed, 
dried or condensed, its value from this point 
of view is not essentially altered by these pro- 
cedures. If a pint of milk daily is included in 
the diet, an adequate supply of calcium is 
probably assured. 

It has not been established that any 
amount of calcium or any other mineral salt 
that is likely to be taken in the diet produces 
in health any ill effects whatever. The soluble 
ones are eliminated chiefly by the kidneys, 
the insoluble ones by the intestines. It is 
well known that very large amounts of 
sodium chlorid may in infants produce seri- 
ous disturbances of nutrition. 



DISTRIBUTION OP CALORIES 139 

It is of course in relation to the production SlSSUSf 
of rickets that the particular interest in the mSSSf 19 
mineral salts of the diet just now centers. forBoile8 
That an adequate intake of calcium and phos- 
phorus is essential to normal bone develop- 
ment is obvious. But rickets occurs con- 
stantly in spite of this. Besides an adequate 
supply in the food there are other conditions 
necessary to a proper utilisation of these sub- 
stances. What these all are we do not as yet 
fully understand. That there is more than 
one dietary factor seems established. 

While therefore mineral salts are so es- 
sential in the diet, we need not fear that the 
requirements of the body in this respect dur- 
ing growth will not be met, unless for long 
periods the diet is a very restricted one, and 
especially if it contains no milk, eggs or green 
vegetables. 

V. Percentage Distribution of Calories. 

Thus far there have been discussed the 
total caloric need and the amounts of the 
different food constituents — protein, fat and 
carbohydrate — which make up the diet of the 
average healthy child. The next point to be 
considered is the relation of these food con- 
stituents to each other, and the relation of 



DISTRIBUTION OF CALORIES 141 

each one to the diet as a whole; in other £2r£Sd 0f 
words, what percentage of the total calories S t n s s S tu " 
shall be given as fat, as protein and as car- Eacl1 0tk6T 
bohydrate. 

In order to determine the usual relation of 
these constituents in the diet of the child we 
have calculated the percentage distribution 
of the calories in the diets taken by the one 
hundred and six healthy children from one 
to eighteen years of age studied by us. The 
result in the individual observations is shown 
in Figure 15. The proportion of the total 
calories taken as protein is shown at the bot- 
tom, that as fat in the middle and that as 
carbohydrate at the top. 

The proportion of the total intake which 
was protein showed the least variation. The 
average of all the cases, regardless of age, 
was 15 per cent; the range was from 11 to 
23 per cent, but over one-half the values were 
between 14 and 16 per cent. 

The r>er cent of the total calories taken as Narrow 

- Variations 

fat varied much more widely. The range was jgjjj^f 18 
from 21 to 51 per cent, but three-fourths of g^^J? 
the values were between 30 and 40 per cent ; h y drate 
the average of all the values was 34 per cent. 
The proportion of the total calories taken 
as carbohydrate also showed wide variation, 
with a range of from 38 to 65 per cent; but 



142 



FOOD, HEALTH AND GROWTH 



Usual Dis- 
tribution in 
Food of 
Healthy 
Children 
Fat 35, 
Carbo- 
hydrate 50, 
Protein 15 



three-quarters of the values were between 44 
and 55 per cent ; the average was 51 per cent. 

There was no regular variation with age, 
although the per cent of the total calories 
taken as protein was slightly higher in the 
early years. 

Although there are fairly wide individual 
variations, it is evident that in the mixed diet 
commonly taken by healthy children the 
calories are distributed with surprising regu- 
larity. The average of the values obtained 
in these oases may be assumed to represent 
the usual distribution. This seems a fair as- 
sumption, when the large number of cases is 
considered, and when it is recalled that those 
observed were not a single group under any 
one supervision, but were children in private 
families in rather scattered localities. Not 
all of the children lived in New York City. 
Several lived in Boston, two in Pittsburg, one 
in the South and many in New Jersey and 
Long Island. 

Eegardless of age, the average distribution 
of the calories taken was as follows: fat 34 
per cent, carbohydrate 51 per cent and pro- 
tein 15 per cent; conveniently expressed in 
round numbers as 35-50-15. Therefore, a 
healthy child takes on the average practically 
one-half his calories as carbohydrate, a little 



DISTRIBUTION OF CALORIES 



143 



more than one-third as fat and only about 
one-sixth as protein. Since a gram of fat 
has two and one-fourth times the caloric value 



DM 


IES 




1 


rHEORKTlCAL 


TOTAL 


OAin 


CALORIES 




BOYS 




CALORIES 




































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Mil 


Y6« 


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tv 






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; 
























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FA 


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tooe 


































































1H YE& 


-S 




t J 




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1 < 




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t 1 


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Fig. 16. 



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RIES 




i 


rHEORETICAL 


TOTAL 




DAI 


LY 


CALORIES - 


■ CIRLS 




calories 














































































































































































































i 










tes 




























•=t. 


':ca 


IK 


ta 


tATt 




~;- : 


.-/"' 


'! 


























' 




n" 




K 






ai 






MOO 








m 


- 


v*- 


,- 


| 




-o 


■ 






N 


T 












;, 






















































































AM M TEAM I 2345«7»8t0 1lttn»4BI8 17B AfiVU 

Fig. 17. 

of a gram of protein, it is evident that in these 
proportions the amounts of fat and protein 
are practically equal, while the amount of 
carbohydrate is a little more than three times 
as great as either the fat or protein. 



144 



FOOD, HEALTH AND GROWTH 



Using the average distribution of calories 
just given the exact requirements in fat, car- 
bohydrate and protein have been calculated 
for the entire period of growth, according to 
the estimated total caloric requirements given 



*t& 


»IES 


THEORETICS 


OAlLt 


CALORIES 


PER 


KILO 


- 


BOYS 


CALORIES 






















































































m 


IN 








































90 


I 




r-- 




































- • : I rr\ 










f; " :; 


m 




















-'i 


«^2^ 




S^SmJ 




' 








£ 






*o 












F»T 






























MHiUS 


























IfiE M TEARS I 23456 7091011ttt3HI5l6!7tt 

Fig. 18. 



°tfS^ 




rHEORETICAL 


DAILT 


CALORIES 




f»ER 


KILO 




6IRL1 




*W« 
























































































































































































■■-: 


v; 






"" 


■ 






" 
































! ' FAT 


| 1 yr^f^^sM 






8 t J 3 4 S 6 7 8 « 








ITEAK 


1 


c : 


I 


i < 


;■ ; 


> f 


S 1 


J I 


f n s?,ab 


mi 



Fig. 19. 

in the preceding lecture. Those for boys and 
girls are given in Figures 16 and 17. The 
per kilo, requirements of both sexes are 
shown in Figures 18 and 19. 

As the variation from the average in the 
total calories which are needed by individual 



DISTRIBUTION OF CALORIES 145 

children is considerable there will undoubt- 
edly be variation in the distribution of the 
calories. If the total caloric requirement is 
increased because of more than average ac- 
tivity, this increase may be met, as has been 
previously stated, by raising the carbohy- 
drate intake alone. 

This would increase the proportion of car- 
bohydrate although the amounts of fat and variations 
protein remain unchanged. When the total 
caloric need is lessened because a child is 
over-weight for height or over-size for age, 
all three constituents of the diet should be re- 
duced proportionally, the normal distribution 
of calories being retained, because the di- 
minished caloric needs for growth permit a 
reduction in the fat and protein as well as 
in the total requirement. On the other hand, 
when a child is under-size for age or under- 
weight for height, the total caloric need is 
greater than the average and the usual dis- 
tribution of calories should be retained, all 
the constituents of the diet being increased. 

The ration usually considered standard for usual 
adults consists of 100 grams of fat, 400 grams tribution 
of carbohydrate and 100 grams of protein 
daily. This gives a distribution of the total 
calories as follows: fat 31 per cent, carbo- 
hydrate 55 per cent and protein 14 per cent. 



146 



FOOD, HEALTH AND GROWTH 



Children 
Need More 
Fat and 
Protein 
than do 
Adults 



German 
Schedules 
Low in Fat 
and High in 
Carbo- 
hydrate 



Murlin calculated the distribution of food 
taken by the soldiers in our army camps to be, 
fat 30 per cent, carbohydrate 56 per cent, pro- 
tein 14 per cent. Neither of these differs very 
widely from the average for children; viz., 
35-50-15. 

The evidence already presented shows that 
children have greater needs for both fat and 
protein than have adults ; hence, a somewhat 
higher proportion of fat and of protein should 
be supplied in their diet than is allowed in the 
adult ration. 

The reports published by other authors of 
actual diets taken by children show, as would 
be expected, considerable variation in the per- 
centage distribution of the calories. In most 
cases, however, the protein taken ranges 
from 15 to 20 per cent of the total. 

The greatest variation is seen in the per 
cent of fat and of carbohydrate. In most of 
the German schedules the proportion of fat 
is considerably lower than that here recom- 
mended. 

In Camerer's schedule the proportions of 
the different constituents of the diet are 
varied with increasing age. He recommends 
37 per cent of the calories as fat at one year, 
but reduces the allowance gradually to 23 per 
cent at five years of age, maintaining this 



DISTRIBUTION OP CALORIES 147 

value throughout the remainder of growth. 
This reduction in fat is met by increasing the 
calories of carbohydrate. In his schedule 
the proportion of carbohydrate rises from 
45 per cent of the calories at one year to 60 
per cent at five years and remains at this fig- 
ure throughout the remainder of the growth 
period. His protein allowance at one year 
supplies 18.5 per cent of the total calories; 
the proportion is diminished to 17 per cent 
at five years and remains at this figure dur- 
ing the remainder of growth. His distribu- 
tion throughout the greater part of the 
growth period, therefore, may be expressed 
as 23-60-17. 

In concluding this discussion, emphasis 
should be placed on the importance of the bal- 
anced ration. The protein need of the grow- 
ing child is very important and there seems 
to be fairly general unanimity as to the 
amount needed. All evidence seems to indi- 
cate that when 15 per cent of the total caloric importance 

c of a Bal- 

need is supplied by protein, the nutritive «£<*£ 
needs in protein are met. The amount of fat 
required is still a debated question, but it 
seems reasonable and desirable to give as 
much fat as protein to the growing child. If 
the amounts of fat and protein taken are 
equal, the protein will furnish 15 per cent of 



148 FOOD, HEALTH AND GROWTH 

the required calories and the fat about 35 
per cent. The remaining caloric need, that 
is, 50 per cent of the total calories, is then 
to be supplied by carbohydrate. 
f When this distribution is deviated from 
to any marked degree and for long periods, 
that is, when what seems to be a proper bal- 
ance of the diet is disturbed, various unde- 
sirable results may follow. If much less fat 
is allowed, the carbohydrate intake is usually 
excessive and digestion may be disturbed in 
consequence. If the fat is too high, the nor- 
mal fat tolerance may be exceeded and diges- 
tion be seriously upset. High fat with high 
protein forms a combination tending to cause 
constipation. Low fat with high carbohy- 
drate may give rise to diarrhoea. 

On the whole, one may conclude both from 
theoretical considerations and practical ob- 
servation that a diet in which the fat supplies 
35 per cent of the total calories, the protein 
15 per cent and the carbohydrate 50 per cent 
is one which meets the nutritive needs of the 
child and is well borne by the digestive or- 
gans ; that is, it is a well-balanced ration. 



CHAPTER IV 

Lecture Four 

Vitamines 

In the study of foods and nutrition the em- 
phasis has changed frequently with the years. 
Formerly foods were valued according to 
their chemical composition — the amount of 
fat, protein, carbohydrate and mineral salts 
which they contained; in infant nutrition in- 
terest centered in the proportions in which 
these different food constituents should be 
given in the diet. A few years later, when 
the energy value of foods was better under- 
stood, foods were valued and used according 
to the calories they furnished. 

At present interest in nutrition is focussed 
upon the "accessory food factors' ' or vita- 
mines. As this is one of the newer fields, it is 
not surprising that it is absorbing the atten- 
tion of most of those interested in nutrition, 
especially from the laboratory point of view. ^sSid 161 * 
It is because the field of investigation is so 
recent and the results which have been ob- 

149 



150 



FOOD, HEALTH AND GROWTH 



Possible 
Dangers in 
Applying 
Eesults 
from Ani- 
mal Experi- 
ments 



served in the studies upon animals, either by- 
adding or withdrawing vitamines from the 
diet, are so dramatic that possibly we are in 
danger just now of losing our perspective 
and of giving too little thought to other fac- 
tors in nutrition which are quite as impor- 
tant, possibly even of more importance than 
the vitamines. Our new knowledge does not 
invalidate the old; it has, however, given a 
new point of view and this is of great im- 
portance. 

In our consideration of this subject we 
must not then fall into the error of thinking 
that the vitamine content of food is really the 
one and only thing that matters. This, how- 
ever, is the impression which one might re- 
ceive from a survey of much recent litera- 
ture on the subject of nutrition. 

Nearly all the laboratory observations 
upon vitamines have been made by men who 
were not physicians ; it remains for the phy- 
sician to test, in their application to human 
beings, the conclusions which have been 
drawn from a study of animals. 

My principal purpose in this lecture will 
be to discuss the bearing of the facts which 
the laboratory workers have demonstrated 
upon the problems of human nutrition, es- 
pecially the nutrition of children. 



VITAMINES 



151 



It seems strange that constituents of our 
diet so important as the vitamines should 
have so long escaped notice. Although physi- 
ologists have had suspicions of the existence 
of some such substances for a long time, yet 
practically all our definite knowledge regard- our fowl- 
ing them is a matter of scarcely more than vitlnSnes 
the last eight or ten years. Recent 

One of the earliest observations that there 
were other substances besides fat, protein, 
carbohydrates and mineral salts, which were 
indispensable to life, was that of Lunin, a Ger- 
man physiologist. Forty years ago while in- 
vestigating the importance of inorganic salts 
in the food he discovered that while mice 
would live for months in health upon a diet of 
milk, they invariably died within a month on 
a ration containing what were supposed to be 
the essential ingredients of milk, viz., casein, 
fat, milk-sugar and salts. His conclusion was 
that there must exist in milk some other 
substances which were indispensable for 
life. 

Other investigators made many attempts 
from time to time to keep animals alive upon 
diets of pure protein, fat, carbohydrates, 
salts and water, but they were invariably un- 
successful when these substances were care- 
fully purified. The failure was variously ex- 



Hopkins' 
Early Ob 



152 FOOD, HEALTH AND GROWTH 

plained as due to monotony of diet, lack of ap- 
petite, absence of flavor in the food, etc. 

It is to Hopkins, Professor of Physiology 
at Cambridge, that the credit belongs for first 
grasping the significance of these other diet- 
servations al y f ac tors and clearly stating the question. 
I cannot do better than to quote the conclu- 
sions from his experiments which were pub- 
lished in 1906. He says : — 

No animal can live upon a mixture of pure pro- 
tein, fat and carbohydrate, even with the addition 
of mineral salts. The animal body is adjusted to 
live upon plant tissues or other animals and these 
contain countless substances other than proteins, 
carbohydrates and fat. Physiological evolution 
has made some of these well nigh as essential as 
are the basal constituents of diet. . . . The field 
is almost unexplored; only it is certain that there 
are many minor factors in all diets of which the 
body takes account. 

Funk in 1911 while investigating the sub- 
ject of beri-beri obtained from rice polish- 
ings a substance which prevented beri-beri 
and also the polyneuritis of birds. As this 
substance contained nitrogen he concluded 
that it belonged to a class of compounds 
known as the amines; as it was essential to 
life he called it a vit-amine. 

In 1912 Hopkins published the results of 



VITAMINES 



153 



ADDITION OF MILK TO PURIFIED FOODSTUFFS 



•••••••GROWTH ON PURIFIED 01 CT 



WITH 3CC MILK DAILY 



GRAMS 




Fig. 20, from Hopkins: By purified foods is meant a 
diet which consists of pure fat, protein and carbohydrate. 
The upper curve shows normal growth when a small amount 
of milk was added to such a diet; growth continued at a 
diminishing rate for about two weeks after the milk was 
omitted; then ceased and soon a loss in weight occurred. 
In the growth represented by the lower curve the experiment 
is reversed ; the animal continued to gain for about ten days 
after the deficient diet was given, and then lost weight; but 
upon adding the milk a marked growth response was seen 
after a few days and thereafter a normal growth continued. 



154 



FOOD, HEALTH AND GROWTH 



Milk Con- 
tained 
Something 
Besides the 
Common 
Food Con- 
stituents 



Something 
Essential, 
Associated 
with But- 
ter Fat 



a series of investigations extending over sev- 
eral years. He found that young rats fed 
upon pure caseinogen, lard, starch, cane 
sugar and salts, lived and grew to some ex- 
tent if these constituents were used in a crude 
state; but if they were carefully purified, 
growth was arrested and death soon followed, 
even though the total food intake was suffi- 
cient. However, he observed that if he added 
to these purified foodstuffs a very small 
amount of milk, the animals continued healthy 
and normal growth ensued (Fig. 20). His 
conclusion was that the substance or sub- 
stances added in the milk were of such a na- 
ture that the body could not manufacture or 
synthesise them. 

Hopkins' investigations mark the begin- 
ning of an appreciation of the importance in 
nutrition of what he termed the " accessory 
food factors." His experiments were re- 
peated by many laboratory workers in dif- 
ferent parts of the world. 

Osborne and Mendel of New Haven con- 
firmed the statements that growth and pro- 
longed maintenance was not possible in rats 
fed on a carefully prepared artificial food 
mixture in which fat was supplied by lard, 
but that the decline in health was promptly 
arrested when butter was substituted for 



VITAMINES 155 

lard. They later found that the active sub- 
stance was only in the fat fraction of butter. 
As the butter used was free from nitrogen, 
phosphorus or anything soluble in water, they 
concluded that the substance could not be the 
same as the anti-beri-beri factor studied by 
Funk. Osborne and Mendel further showed 
that the substance which they found in butter 
was also present in certain other fats — beef 
fat and cod liver oil — but was absent in fats 
of vegetable origin. 

Funk and McCollum had found that rats 
would not grow upon their artificial food mix- 
tures, and also that many of them died with gJJJJgjgs 
symptoms of paralysis which they considered 2?rS* d 
analogous to the polyneuritis of birds (avian 
beri-beri) . With this theory they added yeast 
to their artificial food mixture and an imme- 
diate growth response was the result. Their 
conclusion was that the growth-promoting 
factor was not contained in fats, but in yeast. 

The experiments of McCollum and Davis 
confirmed the observation that rats which 
did not grow upon the artificial ration grew 
when a substance derived from butter and 
eggs and soluble in ether was supplied. They 
also found that this growth was not obtained 
when the fat in the diet was lard or vegetable 
oils. 



156. FOOD, HEALTH AND GROWTH 

It was not until 1915 that the existence of 
Necessary to two separate and distinct accessory food fac- 
Growtii and tors was finally settled definitely. One of 

GROWTH ON DIETS DEFICIENT IN VITAMINES 




Th mouth— 1 ' 



Fig. 21, from Osborne and Mendel, shows that both vita- 
mine A and vitamine B are necessary for growth. In the 
curve to the left, normal growth of rats on a complete diet is 
represented. In the first part of the second curve the diet is 
deficient in both A and B and a steady loss in weight 
occurs; this is not checked by adding vitamine A; but when 
both A and B are supplied normal growth at once begins. 
This growth is immediately arrested when both are with- 
drawn from the diet. In the third curve no growth occurs 
when both A and B are lacking and none occurs when B 
alone is added, but growth promptly follows when both A 
and B are supplied. 



these substances was soluble in fat and was 
removed from the food with the fat ; the other 
had different properties and was soluble in 
water. Both however were present in milk 



VITAMINES 157 

and both were necessary for health and 
growth (Fig. 21). McCollum suggested the 
names "fat-soluble A" and "water-soluble 
B" instead of vitamine proposed by Funk. 
However, the term vitamine has gained such 
currency both in popular and medical liter- 
ature that it is likely to be permanent, in spite 
of the fact that it is generally believed to be 
chemically inexact. Laboratory workers still 
speak of them as the fat-soluble A and wa- 
ter-soluble B, or use the more convenient 
terms, vitamine A and vitamine B. 

That in scurvy also we had to do with a con- 
dition brought about by the absence from the 
diet of an accessory food substance, has been scurvy Due 
made clear by observations upon animals, and v£SSm 
also that this factor was different from both 
vitamine A and vitamine B. 

Scurvy has been known for centuries, es- 
pecially among sailors, and was ascribed to 
cold exposure, sea air and salt meats, sepa- 
rately or in combination. Twenty years ago 
the idea that scurvy was of infectious origin 
gained wide but not general acceptance. As 
early as 1734 Bachstrom correctly attributed 
it to the absence from the diet of fresh vege- 
tables and fruits, observing that these articles 
would not only prevent but would cure 
scurvy. 



158 FOOD, HEALTH AND GROWTH 

In 1895 Theobald Smith, then at Harvard, 
published an observation made upon guinea 
pigs ; that when green food was withheld from 
these animals and a diet of oats, hay and 
water was given, a disease developed char- 
acterised by haemorrhages into the different 
tissues, chiefly about certain joints, which if 
unchecked was fatal in about four weeks af- 
ter the green food was omitted. The disease 
scurvy wa s easily and regularly brought about ex- 
Animais perimentally. The significance of this ob- 
servation was apparently not recognised and 
the condition was not identified with human 
scurvy. 

In 1900 Axel Hoist of Christiania made 
the independent observation that if guinea 
pigs were kept upon a diet of grain and water 
they developed a condition comparable in all 
essential features to scurvy in man. He 
regarded the disease as scurvy and conducted 
a long series of experiments with various 
diets both producing and curing the disease. 
The disease could be prevented and cured by 
the addition to the diet of cabbage, dandelion, 
cranberries and various other substances. 

This susceptibility of certain small animals 
to scurvy has led to a great advance in our 
knowledge of this disease. It has been pos- 
sible to ascertain not only the different arti- 



VITAMINES 159 

cles of food which would prevent it, but the 
relative amounts required for protection. 

For the last five or six years it has been 
generally accepted that scurvy was a defi- 
ciency disease due to the absence from the 
food of a definite factor or vitamine. This is 
conveniently designated vitamine C. 

It is now recognised that there are at least 
three accessory food factors, each of which 
has a perfectly definite and distinct function 
in human nutrition, and that all of them are 
necessary for health and growth. During the 
last few years our knowledge regarding these 
factors has rapidly increased as to their dis- Three 
tribution in the various foodstuffs, also how vitamines 

Known 

they may be injured or destroyed by the vari- 
ous methods of preparing or preserving food, 
the symptoms which are produced in experi- 
mental animals when they are withheld from 
the diet, and the different clinical conditions 
in human beings with which each of these sub- 
stances is more or less definitely associated. 
The fat-soluble or vitamine A was first de- 
tected in butter-fat and egg yolk and these 
foods are rich sources. It is, however, very 
widely distributed among foodstuffs. It is 
present in abundance in most animal fats ex- vitamine a 
cept lard, also in heart, liver and kidney tis- 
sues, many fish oils, especially cod liver oil, 



160 FOOD, HEALTH AND GROWTH 

in which it is particularly abundant. Vege- 
table oils, such as linseed, olive, cottonseed, 
corn oil, etc., contain practically none (Fig. 
22). It is present in green or leafy vege- 
tables, such as cabbage, lettuce, spinach, also 

DEFICIENCY OF VITAMfNC V IN VEGETABLE OILS 

■MtataCROWTH ON DIET OF WHOLE MHK 
SKIMMED MILK 

A*D UNSEED Oil 
OLIVE OIL 




Fig. 22, from Osborne and Mendel, shows that while rats 
make a normal growth upon whole milk, they make very- 
little growth upon skimmed milk alone, or upon skimmed 
milt when additional fat is supplied by either linseed oil 
or olive oil. The longer the feeding experiment was con- 
tinued the more evident was the diet deficiency. 



in alfalfa and clover and other grasses, in 
sweet potato and carrots but not in any ap- 
preciable amount in white potato and beets 
or mangels. Nearly all observers agree that 
vitamine A is stable to the ordinary heat 
used in cooking. 
When this vitamine is withdrawn from the 



sence 
from the 



VITAMINES 161 

diet symptoms do not soon appear. From 
this fact the conclusion is drawn that it can 
be stored up in the body, probably with the S^ 
fat. Fully grown rats can be deprived of aiT l 
it sometimes for months without showing dm 
definite symptoms of failing nutrition; but 
this is not the case with young animals. Usu- 
ally in a few weeks evidences of this defi- 
ciency begin to show themselves. Vitamine A 
seems therefore to be much more important 
for growth than for maintenance. By some 
it has been designated the growth factor. It 
is, however, true that the other vitamines are 
also necessary for growth, though their ef- 
fects are shown in different ways; for man 
and probably for most animals all three are 
indispensable. Since the animal body cannot 
manufacture them, this vitamine as well as 
the other two must be supplied in the food. 
Exactly what is the function of vitamine 
A in nutrition we do not yet know. Young 
experimental animals, usually rats, whose 
food is deficient in this factor, in a few weeks 
cease to grow and soon begin to show other sore 
signs of imperfect nutrition, the most strik- 
ing evidence of which is an inflammation of 
the eyes which begins with swelling of the 
lids and conjunctival infection. If the diet 
is unchanged the process goes on to ulcera- 



Eyes 



162 FOOD, HEALTH AND GROWTH 

tion of the cornea and complete destruction 
of the eye. This condition is known as xer- 
ophthalmia. If before serious structural 
changes in the eye have been produced, a 
very small amount of butter, cod liver oil, 
egg yolk, or any substance rich in vitamine A 
is added to the diet, improvement begins im- 
mediately and in a surprisingly short time 
without other treatment the eye is well. This 
occurs so regularly that it must be regarded 
as a specific action. 

Sooner or later all animals in whose diet 
no vitamine A is supplied decline markedly 
in general health and the death rate is high. 
They show feeble resistance to bacterial in- 
fections, especially of the lungs. 

A diet deficient in this factor produces in 
young dogs after several months bony 
changes which are apparently identical with 
those of rickets. Mellanby from his study 
of these changes would include rickets as a 
deficiency disease, the specific cause of which 
is the absence of vitamine A. This view is 
not generally accepted. 

The precise role of vitamine A in the hu- 
man diet is little understood. Opportunities 
to observe the effects of its complete or al- 
most complete removal from the diet have 
been very limited. In nearly all cases in which 



VITAMINES 163 

this vitamine has been deficient in the diet 
other deficiencies have also existed, which 
make definite conclusions from clinical ob- 
servations difficult. Such observations are, certain 
however, interesting and strongly suggestive, in children 
There has been observed in infants and young 
children suffering from serious disorders of 
nutrition, particularly when living in institu- 
tions, a disease of the eye, called herato-mcir- 
lacia, which closely resembles the xerophthal- 
mia occurring in rats and which is probably 
identical with it. 

In 1904, before vitamine A was known, Mori 
described a disease of this kind seen in Japan. 
The diet of the children observed, who were 
from two to five years old, was chiefly carbo- 
hydrates with a small amount of vegetable. 
Mori attributed the condition to a lack of fat 
in the diet. He found in cod liver oil a spe- 
cific remedy. It is interesting to note his ob- 
servation that the condition could also be 
prevented by chicken livers, cod liver oil 
and other fish oils. 

More recently Bloch of Copenhagen has 
reported in two series of cases a similar dis- 
ease observed in infants who were hospital 
or asylum inmates. In the first series the 
general nutrition of all the infants was very 
poor. The diet was deficient in fat, as the 



164 FOOD, HEALTH AND GROWTH 

infants were receiving only separated milk. 
Without other changes in the food than the 
addition of cod liver oil the eyes began to 
improve almost immediately and in eight 
ah cured days were well. Improvement also occurred 
iJve?oii when whole milk was substituted for the 
skimmed milk, but was much more rapid 
when cod liver oil was added. In some cases, 
where the disease was far advanced before 
treatment was begun, loss of sight occurred. 
The second series of cases were observed 
later in a home containing thirty-two healthy 
children. One group of sixteen got no milk; 
the only fat in the diet was a margarine made 
from vegetable oils. Eight of these children 
developed kerato-malacia. The sixteen in 
another ward received w x hole milk as a part 
of their regular diet. Among them no cases 
of the eye disease occurred. The difference 
in the diet of the two groups was simply the 
whim of the nurse in charge. The cases were 
all cured by cod liver oil. Bloch regarded 
the condition as a specific one due to a de- 
ficiency of vitamine A. 

Ross has recently reported four cases of 
kerato-malacia observed in Baltimore. All 
were in marantic infants and the food in all 
instances had been condensed milk. Three 
died from the general condition shortly after 



VTTAMINES 165 

admission. The fourth recovered with the 
administration of cod liver oil and a change 
of food, first to whole cow's milk and later to 
woman's milk. 

Czerny and Keller described more than fif- 
teen years ago a disease in young children, to 
which they gave the name Mehlnahrschaden; oth6rDl8 . 
a condition produced in their opinion by a £ r r £ e u r t 8 ed A t 
diet excessive in carbohydrates and lacking vitamineA 
in fat. Kerato-malacia was one of the char- 
acteristic symptoms. 

During the war there was observed both 
in adults and children, in districts where food 
was scarce and fats almost unobtainable, a 
dropsical condition usually called "war or 
famine oedema" which was attributed to ab- 
sence of fats from the diet. It is thought 
probable that this was due to lack of vita- 
mine A. 

There is frequently seen in hospitals in 
marantic infants and in those suffering from 
severe digestive disorders, on account of 
which the diet has been greatly restricted, a 
form of general dropsy most often described 
under the term, nutritional oedema, which 
possibly is to be connected with the absence 
of this vitamine. It is seen when on account 
of fat intolerance the food consists almost en- 
tirely of carbohydrates and protein. 



166 FOOD, HEALTH AND GROWTH 

It is to the excess of carbohydrate in the 
diet that the condition has been frequently 
attributed. I have seen it develop when there 
was no such excess but only a starvation diet. 
In one instance an infant of three or four 
months had had for many weeks only barley 
water for food. In my hospital practice the 
most successful dietetic treatment of nutri- 
tional oedema has been, next to woman's milk, 
protein milk, which though low in carbohy- 
drates is relatively high in fat. It is inter- 
esting also to note that several of Bloch's 
cases of kerato-malacia also had general 
oedema. 

In none of these clinical conditions except 
possibly kerato-malacia can one state with 
certainty that the diet deficiency in vitamine 
A was the essential cause. Other factors of 
possible importance were present in prac- 
tically all of them, the most common one being 
a very low food intake. Some adults with 
war oedema had been getting but 800 calories 
a day, the usual allowance for a baby of ten 
or eleven months. 
Advantages The clinical observations referred to indi- 

of Labora- _ 

tor y ln - „ cate how difficult it is to draw conclusions 

vestigations 

in conditions of this kind from a study of 
human beings, and what a large number of 
cases must be critically studied before a point 



VITAMINES 167 

can be definitely established. In feeding ani- 
mals in the laboratory the conditions can be 
controlled, the effects of a single diet defi- 
ciency studied at one time, so that exact and 
definite results can often be established from 
a comparatively small number of experi- 
mental observations. It is for this reason 
that more definite additions have been made 
to our knowledge of the value of different 
foods during the last ten years by laboratory 
methods of investigation than in the previous 
fifty. 

During the last few years the fat in the food 
has by many podiatrists been regarded in in- 
fant feeding as the constituent of milk most 
likely to do harm, and a reduction of the fat 
considered almost the first duty in any dis- 
turbance of nutrition. But it should be 
known that this practice has its dangers. It 
is my own belief and experience that this 
practice has gone much too far and that in 
escaping some dangers that we knew we have 
flown to others which we knew not of. 

Eeturning to the subject of rickets, it may 
be said that the question of its exact causa- 
tion is not yet settled. It has long been be- Jiovl? SSt 
lieved from clinical evidence that a most im- c°ause is 
portant, perhaps the most important, etio- 
logical factor was a deficiency of fat in the 



168 FOOD, HEALTH AND GROWTH 

diet. Mellanby has produced rickets in dogs 
by diets deficient in certain animal fats and 
believes that the antirachitic food factor and 
vitamine A are identical substances. 

Paton and Watson conclude from their ex- 
perimental observations that a liberal allow- 
ance of milk fat neither prevents nor cures 
rickets in laboratory dogs, even when given 
in such large amounts as 14 grams per kilo, 
of body weight ; but if the animals are kept in 
the open country they escape rickets on an 
allowance of less than one gram per kilo. 

Young puppies kept in the country on a 
fat-poor diet escaped rickets; while animals 
of the same litter kept in the laboratory and 
given a fat-rich diet developed rickets. Even 
laboratory animals did not develop rickets on 
a low-fat diet provided they were given par- 
ticular care and provided also the diet was 
in other respects adequate. 

In the experience of many observers milk 
neither prevents nor cures rickets in children. 
That there is a special antirachitic food fac- 
tor and that this is the same as vitamine A 
has not been established. With our present 
cansation knowledge it seems highly improbable. 
Not simple While it is evident that in the causation of 
rickets diet is an important factor it seems 



VITAMINES 169 

altogether probable that more than one diet- 
ary factor exists. Environment, especially 
one which affects the amount of sunlight, is 
also a factor of much importance, since in a 
bad environment small diet deficiencies may 
produce the disease while in a good environ- 
ment they may not do so. 

The water-soluble or vitamine B is now 
considered identical with the antineuritis vi- vitamine b 
tamine. It cures the polyneuritis of birds Grains,' 

Vegetables 

which can be produced by a diet of polished •»* Y « aflt 
rice. It is very widely distributed, being 
found in almost all the foodstuffs examined, 
although in widely varying amounts. It is 
abundant in yeast, eggs, most meats, espe- 
cially in the glandular organs, in all seeds and 
grains, in the latter chiefly in the germ and in 
bran, in nearly all vegetables, especially in 
potato, spinach, cabbage, carrots, turnips, in 
nearly all fruit juices, particularly orange, 
lemon and grapefruit, in nuts and finally in 
milk. The potato is an important source of 
this vitamine in common diets. No difference 
has been found between whole or peeled po- 
tatoes, or between new and old potatoes. 

In the accompanying chart (Fig. 23) are 
shown results of some experiments upon the 
growth of rats by Osborne and Mendel in 
which vitamine B was supplied by different 



170 FOOD, HEALTH AND GROWTH 

GROWTH WITH OTAMfft 'B' FROM DIFFERENT PLANTS 



NORMAL GROWTH 
ALFALFA 

CLOVE* 

TOMATO 

SPINACH 

CABBAGE 

T0RM1P 

CARROT 



190 GRAMS 



POTATO 



3123 



1175 

1174 



3104 



im 



389 



360 



183 



344 



332 



187 



337 



1.0 GRAMS PLART FOOD ABCED 

0.S - - * 



Fig. 23, from experiments of Osborne and Mendel, shows 
the relative value of different plant foods with respect to 
the amount of vitamine B which they contain. The normal 
gain of a rat during eight weeks on a complete diet 
is 90 grams. When vitamine B is supplied by alfalfa or 
clover the gain is nearly twice the average, if one gram is 
added; and even exceeds the average when only one-half 
gram is added. It is evident from the chart that spinach 
is nearly twice, and tomato is more than twice, as valuable 
as potato in the same quantities. The vegetable food given 
in every case was in a dry powdered form. 



foods, and shows their relative value as 
sources of this vitamine. The columns give 
the average gain of the animals in eight 
weeks ; the solid black column when one gram 



VITAMINES 171 

of the vegetable food was given daily; the 
white column, with one-half gram. At the 
top is given the average growth of normal Differmtiie 
healthy rats on their usual food. Alfalfa They nt 
and clover stand at the head and tomato next. Contain 
There is little difference between cabbage, 
turnip and spinach. Practically normal 
growth was obtained with each of these with 
one gram, but not with one-half gram. With 
potato fair growth with one gram, almost 
none with one-half gram. 

Vitamine B is present in yeast in greatest 
concentration, more in brewer's than in 
baker's yeast. The ordinary heat of cooking 
does not affect it to any important degree, nor 
does drying, whether applied to eggs or vege- 
tables. It is removed from wheat in the 
process of milling, being practically absent 
from white wheat flour and from polished 
rice. It is present in whole wheat flour, in 
wheat bran and in whole rice grains. 

When this factor, vitamine B, is removed 
from the diet of young rats and mice the ef- 
fect is seen almost immediately. Within a SuSrS- 
few days appetite fails, growth ceases and m^vITf^a 
soon a decline in the general nutrition is evi- 
dent, which continues with increasing sever- 
ity until the animal succumbs, young rats in- 
variably in less than eight days. In many 



the Diet 



172 



FOOD, HEALTH AND GROWTH 



Immediate 
Improve- 
ment When. 
Added 



rats and dogs there is seen a degree of mus- 
cular incoordination and weakness amounting 
almost to paralysis. If to such animals or to 
birds similarly affected, a food rich in the 
water-soluble vitamine, such as yeast, is 
given, no matter in what manner, an improve- 
ment that is marvelous occurs in a few hours. 
Frequently, after a single feeding, appetite 
returns and animals before almost helpless 
are able to run about and birds to fly as if 
nothing had been the matter. The rapidity 
with which the symptoms are produced and 
cured is in striking contrast to those asso- 
ciated with the withdrawal or administration 
of vitamine A. It would appear that the ani- 
mal has no reserve to draw upon, so that vita- 
mine B must be given continuously or nutri- 
tion is disturbed. 

What the function of this accessory factor 
in normal nutrition is, we do not know. That 
it is as essential to man as to animals, clini- 
cal experience abundantly proves. Long be- 
fore the existence of such substances as those 
we are considering was suspected, the dis- 
ease beri-beri was connected with certain diet 
deficiencies. Beri-beri is a very common con- 
dition in certain parts of Asia, but rarely 
seen in this country. As early as 1897 the 
association of beri-beri with a diet deficiency 



VITAMINES 173 

was observed by Eijkman in a prison in Java 
where the food was largely polished rice. He Beri-beri 
noted also that poultry fed upon rice refuse k^owS s di 8 . 

©cLH6 "Pro- 

from the table developed paralysis much like duced 
that seen in his prisoners with beri-beri. The 
condition was cured by the administration of 
rice polishings, or an alcoholic extract of 
them. Vordermann made, Eijkman states, an 
exhaustive study of all the prisons in Java 
and found that everywhere the occurrence of 
beri-beri was in direct proportion to the ex- 
tent to which highly milled rice was used as a 
food. In the prison diet the other articles of 
food were for the most part poor in this vi- 
tamine. The connection between beri-beri 
and the use of polished rice as a staple article 
of food has been noted by many observers in 
different parts of the world. 

The use of a limited diet in which bread 
from white wheat flour forms a very large 
part, has also been followed by similar symp- occurs when 

!<! i j. n i White Bread 

toms, although not usually so severe in de- FormsLarge 
gree. In Labrador and Newfoundland beri- 
beri was unknown when bread was made from 
whole wheat flour. Since the introduction of 
white flour it has become a frequent disease 
and is prevented chiefly by the consumption 
of potatoes. When the supply of potatoes 
fails, outbreaks of beri-beri are common. The 



Part of Diet 



174 FOOD, HEALTH AND GROWTH 

same thing has been witnessed in Ireland 
during a potato famine. 

Hoist states that in Norway great sympa- 
thy was aroused for the hard lot and poor 
food of the sailors, and in 1894 in response 
to public agitation shipmasters were com- 
pelled to supply sailors with bread made from 
white wheat flour or wheat and rye flour. 
After this went into effect beri-beri, unknown 
when their bread was made from whole rye 
flour, became a frequent disease. 

The British Army reports contain some in- 
teresting facts bearing upon this subject. 
During the siege of Kut-el-Amara in the re- 
SikBread cen ^ war > heri-beri occurred among the Brit- 
ish soldiers who received white bread but not 
among the Indian troops whose bread was 
made from a coarse whole wheat flour. At a 
later stage of the siege, when the supply of 
white flour was exhausted and the British sol- 
diers were compelled to eat the coarse bread 
of the Indian troops, the development of beri- 
beri ceased. 

When the diet of the mother is lacking in 
this food factor, her milk is also deficient. It 
is reported that among the Filipinos beri- 
beri is common among the nursing children of 
rice-eating mothers of those islands. This is 
believed to be a large factor in the extremely 



No Beri-beri 



VITAMINES 175 

high infant mortality which is seen there. 

The wide distribution of vitamine B in our 
common foods makes it improbable that 
under normal peace conditions either adults 
or children suffer from a deficiency of this 
in their ordinary diet, particularly since cook- 
ing and drying do not destroy nor greatly in- 
jure it. 

The antiscorbutic or vitamine C differs in 
some very important particulars from the %g™£ 
two which have "just been considered. It is S?* N . eed „ 

° Vitamine C 

the only one of the vitamines that is especially 
sensitive to heat. Certain animals, e.g., rats 
and dogs, have generally been regarded as 
not susceptible to scurvy, i.e., not requiring 
this vitamine for health and growth. The 
recent experiments of Harden, Zilva, and of 
Drummond at the Lister Institute throw 
doubt upon this belief in the case of rats at 
least. They state that while upon a scorbutic 
diet these animals gain weight, grow and even 
reproduce and show no definite symptoms for 
months, yet they do not thrive as well as ani- 
mals which get the antiscorbutic vitamine. 

More extended investigations and morte 
carefully conducted experiments have shown 
in the case of each one of the vitamines that 
they were present, frequently to be sure in 
very small amounts, in many foodstuffs from 



176 



FOOD, HEALTH AND GROWTH 



Chiefly 
Found in 
Fruits and 
Vegetables 



May be 
Injured 
or Even 
Destroyed 
by Heat 



which they were supposed to be entirely ab- 
sent. This and the very small needs of some 
animals may be the explanation of the appar- 
ent insusceptibility to scurvy. 

Further investigations are certainly nec- 
essary before we can regard it as definitely 
established that certain animals do not re- 
quire vit amine C. 

This vitamine is found chiefly in fruits and 
vegetables. It is very abundant in the 
orange, lemon and grapefruit but curiously 
not in the lime, and there is none whatever 
in the preserved lime juice. Cabbage and to- 
mato are especially rich sources, also the 
swede (yellow turnip). There is a moderate 
amount of this vitamine in potato, in the 
green vegetables, in fresh meat and a small 
amount in milk. Cereal grains have none; 
but Frohlich has discovered that if grains are 
moistened and allowed to germinate for a 
few days the antiscorbutic substance is de- 
veloped. 

A particular interest in this connection at- 
taches to the preparation and preservation 
of the food, since this vitamine is nearly al- 
ways injured and may be destroyed by heat, 
either that used for cooking or for the preser- 
vation of foods. The amount of injury done 
is in some cases very well known ; in others, it 



VITAMINES 177 

is still a matter of debate. Canned vege- 
tables (string beans and cabbage have been 
especially studied) lose, according to the ex- 
periments of Chick and Campbell, from 70 
to 90 per cent of their antiscorbutic potency. 
A still further loss occurs from storage, so 
that their value when used is practically nil. 
Cabbage, boiled for one-half hour either with 
or without the addition of acid or alkali, is 
still an efficient antiscorbutic but has lost 
about four-fifths of its value. Dried cabbage 
and dried tomato retain much of their vita- 
mine ; dried fruits, a small amount. 

Canned tomatoes are an efficient antiscor- 
butic, but must be given in somewhat larger 
amounts than fresh tomatoes. It has been 
found that foods which are kept in sealed 
containers retain their vitamines longer than 
those in open packages ; this is attributed in 
part to prevention of oxidation. 

In dried orange and lemon juice the vita- 
mine is very slightly if at all impaired and 
when kept in sealed packages they retain 
their antiscorbutic activity indefinitely. I 
have cured scurvy in infants with dried 
orange juice that had been kept in a sealed 
package for over one year. It appeared to 
be quite as efficient as the equivalent amount 
of the fresh juice. 



178 



FOOD, HEALTH AND GROWTH 



Dried Vege- 
tables of 
No Value 



Amount of 
Vitamlne C 
in Milk 
is Small 



That dried vegetables are practically 
valueless as antiscorbutics was shown as long 
ago as the Crimean War, and the observa- 
tions have been confirmed in all the subse- 
quent wars in which they have been tried. 

Fresh meats are antiscorbutic if the 
amount taken is liberal. Arctic explorers 
have subsisted for months with no other 
source of this vitamine in their diet and have 
been free from scurvy. But this is not true 
of canned meats; they are practically with- 
out antiscorbutic value. The British sol- 
diers while besieged in Kut ate freely of 
fresh horse flesh and escaped scurvy ; the In- 
dian troops, however, who are vegetarians, 
suffered severely from it, as they could get 
no fresh vegetables. 

From the point of view of the nutrition of 
children, the chief interest attaching to the 
effect of heat upon vitamine C relates to 
the heating of milk. In the first place it 
should be understood that the amount of this 
vitamine in fresh milk is very small. How 
small may be appreciated by the fact that 
Chick and Hume found that to protect a 
guinea pig, whose food contains no other 
source of this vitamine, 100 c.c. daily of fresh 
milk are required, although complete pro- 
tection is secured by 1.5 c.c. of orange juice. 



VTTAMINES 179 

It is well established that all heating of 
milk (I do not, of course, mean warming for 
feeding) whether by boiling, pasteurising, 
sterilising, drying or condensing, injures this 
vitamine, though it does not seem to affect 
either the vitamine A or vitamine B. The 
amount of injury done to the antiscorbutic vi- 
tamine depends upon the height of the tem- 
perature and the length of the period during 
which the temperature is maintained, and HeatSe* 7 
possibly upon whether the heating is done in 
open or sealed vessels. The duration of the 
heating seems clearly quite as important as 
the temperature employed. Short heating at 
a high temperature apparently does much less 
injury than prolonged heating at a lower tem- 
perature ; so far as its effect on the vitamine 
is concerned, boiling for five or ten minutes 
seems less harmful than pasteurising for 
thirty minutes. 

While there is still considerable difference 
of opinion among investigators as to the rela- 
tive amount of damage done by various types 
of heating, it may be regarded as proven 
that they all injure milk in this respect to f^ uUcs 
some degree and that the only safe rule in SnSints 
practice is to supply some efficient antiscorbu- HeatSauik 
tic in the diet of all infants reared upon milk 
treated in any one of these ways. 



180 FOOD, HEALTH AND GROWTH 

The time when it is necessary to begin f rait 
juice or other antiscorbutic will be influenced 
by the incubation of scurvy, i.e., the time 
when symptoms appear after the scorbutic 
diet is used. 

In the guinea pig, which is one of the most 
susceptible animals, symptoms of scurvy reg- 
ularly begin after about three weeks. The 
monkey, a rather less susceptible animal, 
shows symptoms of scurvy after about three 
months. Hoist and Frohlich mention the case 
of a fanatical vegetarian who undertook to 
live upon bread and water and who developed 
symptoms of scurvy after seven and a half 
incubation months. They give the story of a Eussian 
refugee who was confined with 1400 others in 
a Russian prison where the diet consisted of 
bread, tea and a cabbage soup. This soup 
was so filthy in appearance that he and about 
twenty other refined people simply could not 
eat it. In about six months he and his group 
developed scurvy. The rest of the inmates 
who took the soup did not. 

Definite symptoms of infantile scurvy are 
most frequently seen from the seventh to the 
tenth month of age, rarely earlier than the 
sixth month, and even the indefinite symp- 
toms of scorbutic malnutrition seldom more 
than a few weeks before this time. 



of Scurvy 



VITAMINES 181 

In my own clinical experience when the sole 
food has been pasteurised or sterilised milk, J 



Usually 
to 



symptoms of scurvy do not usually appear gg t 1 
until this diet has been continued for from Month8 
five to eight months. Of the last nine cases 
of infantile scurvy treated in my hospital 
service, the period was between five and seven 
months in seven cases and in none more than 
nine months. Evidently the body has a suffi- 
cient store of this vitamine to meet its needs 
for a considerable period; when this is ex- 
hausted symptoms appear. If the food con- 
tains even a small amount of vitamine C, the 
development of scurvy will be delayed. 

To infants whose principal or sole food is 
any one of the forms of heated, dried or con- 
densed milk, it would appear then to be quite 
sufficient if an antiscorbutic were begun at 
the age of four or five months, although there 
is no objection to giving it at an earlier 
age. 

As to the amount of the vitamine required 
we have no very definite knowledge; al- 
though the relative value of different foods 
as antiscorbutics has been pretty well deter- 
mined by Chick and Hume (Fig. 24). Ac- 
cording to their experiments the susceptible 
guinea pig needs daily for complete protec- 
tion about 100 c.c. of fresh cow's milk or 1.5 



182 



FOOD, HEALTH AND GROWTH 



Amount of 
Orange 
Juice 

Needed for 
Protection 



c.c. of orange juice; that is, orange juice is 
about sixty times as potent an antiscorbutic 
as is fresh cow's milk. The monkey, whose 
weight is about ten times as great, requires 
only about twice as much of either for protec- 



NEEDED TO PREVENT SCURVY IN GUINEA PIGS 



OREO TOMATO 


■ 1GM DAILY 




RAW CABBA6E 


a ISM 




LEMON JUICE 


H1.SCC 




ORANGE JUICE 


RRH.SCC 




SWEDE JUICE 


8B3 2.SCC 




COOKED CANA6E 


RBassa SGM 




GERMINATED LENTILS 


HHRBHRRLSGM 




STRING" BEANS 


■HBBR15GM 




RAW TOMATO 


NRXBBBZBE9B10GM 




CARROT JURE 

BOILED POTATO 

BEETROOT JUICE 

CRAPES 

RAW MEAT JUICE 

RAW COW'S MILS 















In Fig. 24, based upon experiments of Chick and Hume 
of the Lister Institute, are shown the relative richness of 
common articles of food in vitamine C. Tomato, cabbage, 
orange and lemon juice stand at the top; of these only one 
gram or 1.5 c.c. respectively, are needed for protection, 
while of fresh cow's milk which stands at the bottom more 
than 100 c.c. is needed. 

tion as does the guinea pig. If the human in- 
fant were as susceptible as the guinea pig 
there would be needed weight for weight 
about two quarts of fresh milk daily, or one 
ounce of orange juice, at the age when scurvy 



VITAMINES 183 

is most often seen. Practically we find that 
those who get even somewhat less than one 
quart of fresh cow's milk very seldom de- 
velop scurvy. It would seem then that 15 c.c. 
or half an ounce of orange juice daily was, 
under average conditions, ample for protec- 
tion in the latter half of the first year. 

Of the common antiscorbutic foods, orange 
juice is undoubtedly the best, but is some- 
what expensive and not always obtainable. 
The dried orange juice, not yet on the general 
market, seems almost if not quite as effective 
and does not lose its activity by keeping. 
Dried orange and lemon juice seem likely to 
prove some of our most convenient anti- 
scorbutics. 

I have had no personal experience with the 
juice of the swede but the experiments of 
Chick and Hume at the Lister Institute indi- _„ . M 

Other Anti- 

cate that this is quite as effective as orange scorbutics 
juice in the same quantities. It is grated and 
the juice squeezed out in a cloth by hand. 

The juice of fresh raw or canned tomatoes 
is cheap and effective as an antiscorbutic. It 
is perhaps a little more likely to disturb the 
digestion than is orange juice, but can be 
given to most infants without any difficulty. 
I have found it effective both in preventing 
and in curing scurvy, but it must be given in 



184 



FOOD, HEALTH AND GROWTH 



Conditions 
Which May 
Interfere 
With the 
Action of 
Vitamine 



somewhat larger doses than orange juice and 
the seeds carefully strained out. 

Are there conditions present in disease, 
particularly of the digestive tract, which may 
interfere with either the absorption or the 
activity of vitamines, so that the conse- 
quences of a deficiency may exist even though 
these substances may be given in the food in 
adequate amounts! We do not yet know. 
But so far as the vitamine C is concerned this 
seems not improbable, particularly in diar- 
rhceal conditions. All who have seen much 
of infantile scurvy know the difficulties in 
treatment when diarrhoea is present or is 
easily excited. Of course diarrhoea may be 
present as one of the symptoms of the 
scurvy. A concentration of the vitamine by 
removing from orange or lemon juice all the 
vegetable acids has been used by Chick and 
Still in such cases as these with most satis- 
factory results, without causing any disturb- 
ance of the bowels. With this concentrated 
preparation much larger amounts could be 
administered and very prompt cure effected. 

I have myself seen scurvy develop in a 
hospital patient while under observation and 
while taking as much as 30 c.c. of orange 
juice daily. In this case no acute diarrhoea 
was present but there did exist a serious 



VITAMINES 185 

chronic disturbance of digestion with a tend- 
ency to looseness of the bowels. 

Future investigations may reveal the fact 
that vitamine deficiency is a cause, which we 
do not now suspect, of some of the symptoms 
seen in certain chronic diseases. This is less 
likely to be the case in acute disease as it is 
so long before effects of deficiencies in vita- 
mine A or vitamine C are evident. 

While we have learned a great deal regard- 
ing what vitamines do, we know very little Jg*gJ> 
else about them. None of them has as yet been »troy vita- 

» mines m 

isolated. The effect of heat upon vitamine A Food 
has not been definitely settled. Hopkins ' 
recent experiments with butter fat indicate 
that heat in sealed vessels does not injure the 
vitamine even though prolonged and the tem- 
perature high, while moderate heat with aera- 
tion destroys it ; also that if butter is exposed 
to the air in thin layers for long periods it 
loses its vitamine. The inference is that it is 
destroyed by oxidation. Most experiments 
indicate that this vitamine is stable to ordi- 
nary heat used in cooking unless the heat is 
very prolonged. 

Vitamine A is soluble in alcohol and ether. 
Osborne and Mendel have extracted with 
ether from the green leaves of plants, using 
spinach, clover, alfalfa, an oily substance with 



186 



FOOD, HEALTH AND GROWTH 



Solubility 
of Vita- 
mines 



Vitamines 
Must be 
Continu- 
ously Taken 
with the 
Food 



which they secured growth quite equal to that 
obtained with butter fat. 

Vitamine B, now generally regarded as 
identical with the antineuritic vitamine, is 
soluble in water but not in alcohol or ether. 
It is unaffected by ordinary temperatures 
used in baking or boiling, but may be injured 
by prolonged heating at high temperatures. 
Osborne and Wakeman succeeded in concen- 
trating the vitamine from brewer 's yeast but 
not in isolating it. 

Vitamine C is soluble in water and alcohol 
and passes through porcelain niters. From 
the fact that acid fruit juices retain their 
value much longer than vegetable juices, 
Hoist concludes that the antiscorbutic vi- 
tamine is more stable in acid than in neutral 
media. Harden and Zilva have shown that 
it is rapidly destroyed at room temperature 
by dilute alkalies. Oxidation seems also to 
injure it. 

I have already alluded to the fact that the 
animal body cannot manufacture or synthe- 
sise vitamines. They are constant body needs 
and must be taken in continually with the 
food. The belief at present is that they are 
synthesised in plants; the herbivorous ani- 
mals get them from plants, the carnivora from 
the herbivora. 



VITAMINES 187 

Hart, Steenbock and Ellis have made the 
important observation, since confirmed by 
others, that the vitamine content of cow's 
milk is affected by the food of the animal. 
This was first shown to be true of the anti- 
scorbutic vitamine. The winter milk of stall- 
fed animals was decidedly poorer in this re- 
spect than the summer milk of pastured ani- 
mals. 

From investigations made by others this 
same law seems to apply to all the vitamines. jJei&od 
If the food of the cow does not contain an JSJUJjjJ, 
adequate supply, the milk may be deficient 
in any or in all of them. 

The same rule applies to the nursing 
mother. This may furnish a clue to some of 
the puzzling cases of scurvy developing in 
nursing infants. It may also explain why 
infants do not thrive upon some milks, al- 
though the supply is abundant and the pro- 
portion of the different constituents, as 
shown by chemical analysis, is within the nor- 
mal range. 

The important practical application of Essential 
these facts is, first, to recognise the necessity SaSSing 
of supplying to nursing mothers a diet which MoUler 
is ample in all the vitamines. Vitamine C and 
vitamine A are the ones most likely to be lack- 
ing in the diet of the poor. These are abun- 



188 FOOD, HEALTH AND GROWTH 

dantly supplied by milk, eggs, green vege- 
tables and fruits, all of which unfortunately 
are expensive foods, but they should be in- 
cluded in the diet. 

It would seem in the diet of children, par- 
ticularly infants, a wise precaution during 
the winter to supplement cow's milk by other 
cod Liver foods known to be rich in vitamine A, such as 
wLSr butter, the yolk of egg or the juice of steamed 
green vegetables, but best of all by cod liver 
oil; small doses will probably suffice, i.e., a 
half teaspoonful of the pure oil daily for an 
infant of nine or ten months of age. Defi- 
ciency of vitamine C in winter milk, which 
may exist even though milk has not been 
heated, should be corrected by giving orange 
or tomato juice. 

Our knowledge of vitamines is as yet only 
partial and very incomplete. We are really 
only at the beginning of a line of research in 
nutrition which has possibilities we can 
hardly foresee. Constant additions are be- 
ing made to our knowledge ; and many things 
generally accepted one or two years ago are 
now shown to be erroneous. 

Scientific research along any line is diffi- 
cult ; the pitfalls for the untrained and inex- 
perienced are numerous, and it is not sur- 
prising that many premature and unwar- 



VITAMINES 189 

ranted conclusions have been drawn from 
laboratory observations in the investigation 
of vitamines. 

One of the early errors was due to the fact 
that the purified foodstuffs composing the so- 
called "basal diet" supposed to be free from f£^f 6 a s rly 
vitamines were not pure. Vitamines exist in 
food in very small quantities, and some arti- 
cles which were long believed to contain none 
have been shown to have enough, if large 
amounts of the food in question are taken, to 
vitiate the result of an experiment. Or, take 
the question of the amount of milk required to 
maintain growth. Equally good observers 
have gotten quite contrary results in their ex- 
periments. We now know that the vitamine 
content of milk is not constant but varies with 
the food of the animal. 

Lard has been regarded as the one notable 
exception to the rule that animal fats are 
rich in vitamine A. The process used in re- 
fining commercial lard, however, is in all es- 
sential features identical with the process 
which Hopkins has recently shown to be de- 
structive to vitamine A in butter. Its absence 
therefore from lard seems to be explained by 
the process used in its preparation. 

Again, when orange juice was added to the 
diet, the effects which followed were at- 



190 



FOOD, HEALTH AND GROWTH 



Widely 
Distributed 



Vitamins 
not yet 
Isolated 



tributed to the antiscorbutic vitamine. But 
Osborne and Mendel have shown that this 
and some other fruit juices are also rich in 
vitamine B and even contain some vita- 
mine A. 

We are constantly learning how widely dis- 
tributed the vitamine s are in all natural food- 
stuffs, but may be injured by methods of prep- 
aration. Milk contains much vitamine A, a 
moderate amount of vitamine B and some vi- 
tamine C. Tomato, cabbage and many other 
green leafy vegetables contain all the vita- 
mines. The potato has considerable of vita- 
mine B and vitamine C and even some vita- 
mine A. Even cod liver oil, the rich source 
of vitamine A, contains many other sub- 
stances which may profoundly affect nutri- 
tion. 

It seems quite evident that until these sub- 
stances which we call vitamines have been 
isolated, the interpretation of experiments 
along this line is open to error. Clearly, until 
this has been accomplished many of our con- 
clusions from animal experiments must be 
regarded as tentative only. 

Again, there is a risk in drawing too 
sweeping inferences from the results of ex- 
periments upon small animals. Almost all 
the observations thus far have been made 



VITAMINES 191 

upon rats and guinea pigs. We have already- 
seen in the case of scurvy that the suscepti- 
bility of different species of animals to a de- 
ficiency in vitamine C differs enormously. 
This may also be found to be true of the other 
vitamines also. 

The great service thus far rendered in the J^^SSa 
study of vitamines has been twofold : first, it values d 
has given a new basis for the evaluation of 
foods, and secondly, it has shown what dam- 
age may be done to natural foods by the meas- 
ures employed in refining or preserving 
them. 

Out of the searching examination to which 
all our foods have been subjected, two, 
hitherto much neglected and often placed at 
the foot of the class, have emerged with high 
honours, viz., the cabbage and the tomato. 
These and other articles which from the point 
of view of their energy value are almost 
worthless have been shown to possess a nu- 
tritive value which is very great. They fur- Chemical 
nish something more than flavor to food, to ££es y Not 
make it more appetising, something very es- v^Tef 00 * 
sential in a human diet. The importance of 
some foods in diet is not suggested by chem- 
ical analysis. The tomato, cabbage, spinach, 
lettuce, chard and all the green or leafy vege- 
tables are composed chiefly of cellulose, water 



192 



FOOD, HEALTH AND GROWTH 



Injured by 
Methods of 
Handling 
and Pre- 
serving 
Foods 



Wnat We 
Lose by 
This 



and inorganic salts. Fruits have sugar, vege- 
table acids, water and salts; but none of 
these things suggest their essential value in 
diet. 

Many of our foods we no longer eat in their 
natural state. The conditions of modern life 
have made necessary the transportation of 
foods for long distances and the preservation 
and storage of food in immense quantities for 
long periods. A certain amount of injury is 
done to our vegetables, fruits, milk, meats and 
grains by the processes to which they are sub- 
jected in preparation, preservation and stor- 
age. The study of vitamines has helped us to 
understand, to some degree at least, the na- 
ture of the harm that has been done. Some of 
this occurs from the heat applied during our 
ordinary processes of cooking ; some is a con- 
sequence of heat applied for purposes of 
sterilisation, whether for the destruction of 
the germs of disease or for the preservation 
of food by canning. 

Another example is what we have sacri- 
ficed in their nutritive value by the refinement 
of our foods, as in polishing rice and using 
only the white flour of our wheat to make our 
bread, feeding to pigs and cows the bal- 
ance of the grain. The coarse black bread of 
the Middle Ages and of the European peas- 



VITAMINES 193 

ant of today is despised by our modern civil- 
ised city dweller. 

But there is another side to the question ; gjfi* We 
let us not at the same time forget the immense 
benefits of the preservation and storage of 
food. Take for example the question of white 
wheat flour. As long as wheat was grown and 
milled in this country, as it still is in most 
European countries, within a comparatively 
short distance, seldom more than one or two 
hundred miles of where it was consumed, 
and was used within a few weeks of milling, 
the problem was a simple one. 

At present much of our milling is done one 
or two thousand miles from our large centres 
of population. Not only must the time re- 
quired for transportation be taken into ac- 
count, but the necessity for storage of very 
large quantities as a normal food reserve. 
New York City, for instance, consumes over 
20,000 barrels of flour every day. Very much 
of this, it is estimated, has been milled five or 
six months before it is consumed. White 
wheat flour keeps indefinitely, certainly for w^i* 
six months, without any important deteriora- Soufwm 
tion. But whole wheat flour can be kept only Long eop 
about thirty days ; after that it is likely to be- 
come "wormy" from the development of ova 
which are deposited in the husk. One whole 



194 



FOOD, HEALTH AND GROWTH 



Advantages 
of Heated 
Milk, Dried 
and Canned 
Foods 



cargo of 1000 barrels sent to Glasgow during 
the war had to be thrown away for this 
reason. 

Flour experts tell us that the general adop- 
tion of whole wheat flour for bread in this 
country is an economic impossibility. But 
the modern method of milling and our system 
of transportation and storage make a bread 
famine here almost impossible. In China, 
however, without facilities either for trans- 
portation or storage, there may be famine in 
one province when wheat is abundant and 
selling, Thos. W. Lamont tells us, for a few 
cents a bushel in another province. 

Although heating milk may injure or de- 
stroy its antiscorbutic vitamine, this fact does 
not invalidate its great advantages, such as 
protection from diseases which may be com- 
municated through milk, and the preserva- 
tion of milk by drying, condensing or sterilis- 
ing which permits its wider use as a food all 
over the world. 

The same may be said of the canning and 
drying of vegetables, fruits and eggs. These 
preserved foods are of great benefit in the 
nutrition both of children and adults. We 
could not stop the use of them if we would, 
and we would not if we could. 

Our present knowledge of vitamines has 



VITAMINES 195 

pointed out that these same procedures have 
their disadvantages, even their dangers ; but 
when the nature of these is once thoroughly 
understood and their importance appreciated, 
the remedy will come also; possibly in some 
improvement in the processes now in use, or 
it can always be done by supplying in the diet 
by other articles of food the particular vi- 
tamine which has been injured or destroyed. 

The food of infants or older children is in 
normal times almost never lacking in vita- 
mine B. It is the antiscorbutic vitamine only 
that is likely to be injured by any process to 
which their food is subjected in preparation 
or preservation. But I have never seen and 
have never known of a case of scurvy in a 
child over two years old who was living under 
normal peace conditions. So far as vitamine 
A, so indispensable for the growth of chil- 
dren, is concerned, it is necessary only that 
care be taken that the diet include an ample 
supply, since it is not likely to be injured in 
the preparation or preservation of food. 

We know well the dangers of vitamine de- 
ficiency when the diet is necessarily restricted conditions 

- J when Vita- 

because conditions do not admit of choice or mine Defi- 
ciency is 

variety of food. These conditions exist in "*** 
times of famine, or great food shortage, or 
even may be the result of poverty, also in 



196 



FOOD, HEALTH AND GROWTH 



Deficiency 
Unlikely if 
Usual Diet 
is Taken 



Amount 
Necessary 
not Known, 
Probably 

Not Large 



prisons, army camps, on ship-board, in Arctic 
regions and, one must add, in infancy. 

The consequences to children are serious, 
whether we consider simply arrested growth 
and general malnutrition, or the diseases 
like scurvy and beri-beri, which result from 
marked and prolonged deficiencies. But it is 
not likely that, except in conditions like those 
mentioned, either children or adults who take 
the average or usual diet are likely to receive 
such small quantities of the vitamines as defi- 
nitely to interfere either with healthy growth 
or normal nutrition, 

A glance over the list of foodstuffs known 
to contain the different vitamines shows how 
abundant vitamines are in most common 
foods. This may be one of the reasons why 
in the evolution of the diet of the human race 
certain foods have held their place. 

It seems therefore perfectly evident that 
unless the diet given is a very one-sided one, 
children receive in their usual food a liberal 
supply of all these essential food constitu- 
ents. This will be certain to be the case if the 
regular diet includes milk, green vegetables, 
fruits and cereals. 

There are two very striking things brought 
out in the investigation of vitamines by the 
observation on animals : One is the very small 



VITAMINES 197 

amounts which are apparently required to 
produce their effects and the other is the 
specificity of their action. Until these sub- 
stances have been isolated we shall not know 
the amounts required for normal nutrition. 
Apparently the amount of any one of them 
is not large. 

Chick, Drummond and their associates at 
the Lister Institute have shown how much of 
different foods is required to protect labora- 
tory animals against beri-beri and also 
against scurvy, when the diet contained no 
other source of the vitamine in question. 
They determined, for example, how much of 
orange juice, cabbage, tomato and many other 
foods was needed to prevent scurvy ; and how 
much of potato, yeast, egg and many other 
foods was needed to prevent beri-beri. 

While this establishes much that is impor- Require- 
tant with regard to the relative value of cer- with otLr 

. . . Conditions 

tain foods, it gives us no idea as to the actual 
amounts of vitamine required by human be- 
ings. All the evidence goes to show that the 
vitamine requirement is affected by many 
conditions. It undoubtedly varies widely 
even in animals. Laboratory animals in con- 
finement might be expected to show effects of 
deficiencies in diet sooner than those living 
under natural conditions. It has often been 



198 



FOOD, HEALTH AND GROWTH 



Especially 
Important 
for Growth 



Infancy the 
Period of 
Most 
Danger 



observed that men who were much exposed 
and doing hard work were affected by scurvy 
sooner than others, although all had the same 
diet. If the human diet is poor in other re- 
spects the effects of the absence of the anti- 
scorbutic or any other vitamine are more 
quickly apparent. 

How much of the different vitamine s is 
needed for health we do not yet know. It is 
clearly not a definite amount for all human 
beings of the same age, sex and weight, but 
like our other food requirements the vitamine 
need no doubt varies with many conditions. 

The special importance of vitamines for 
growth makes it imperative that the diet of 
children should contain the articles already 
enumerated which are rich in these factors. 
The requirements of adults are for mainte- 
nance merely and undoubtedly are much less 
than the requirements of children. This is 
especially true of vitamine A. 

It is during the period of infancy that chil- 
dren are likely to suffer most; first, since 
infants are the most susceptible of human be- 
ings to all adverse conditions; secondly in- 
fancy is the period of most rapid growth and 
anything which may affect growth produces 
its most marked effects at this time ; finally, 



VITAMINES 199 

the diet of infancy is necessarily a restricted 
one. 

It is not only the infant who is artificially 
fed who may suffer from vitamine deficiency. 
The mother must take them in with her food 
if she is to give them out in her milk. This is 
true of any of the vitamines, but is especially 
important in the case of vitamine A, the need 
of which seems especially marked in infancy. 

With infants who are fed upon cow's milk 
we are rather more likely to see evidences of 
vitamine deficiency in the winter or early 
spring months than in summer and fall. 

Proprietary infant foods are dangerous 
not so much from what they contain as from 
what they lack. They may be deficient in all 
three of the vitamines. Cereals have practi- 
cally no vitamine A or vitamine C, and the 
dangers of deficiency are likely to exist just 
in proportion to the extent to which they 
form a part of the diet. 

The specificity of action of these substances 
is quite as great as that of antitoxin in diph- 
theria or thyroid extract in cretinism. The |J^f vitL 
different vitamines seem entirely indepen- gScific 
dent of each other in their activity. They are 
in no way interchangeable ; they seem to have 
no relation to one another. We cannot sup- 
ply a deficiency in vitamine B by giving more 



200 FOOD, HEALTH AND GROWTH 

of vitamine A, nor can we protect against 
scurvy by the most liberal allowance of vita- 
mine B. Each one has a perfectly definite 
function in nutrition; which, from evidence 
now in our possession, can be performed by it 
but by nothing else. If no vitamine deficiency 
exists in the diet, it does not seem probable 
that symptoms of malnutrition will be im- 
proved by giving vitamines in excess; it 
would be surprising if it were so, and we lack 
evidence that such is the case. 

Another practical question is whether if 
the diet is low in its vitamine content, i.e., a 
condition of relative deficiency exists, there 
symptoms may occur, perhaps not frank scurvy, beri- 
neiative beri, or kerato-malacia, but milder and less 
definite symptoms, such as failure to make 
normal progress in growth, malnutrition, and 
general evidence of ill health. This is some- 
thing difficult to establish. On a priori 
grounds it seems not improbable. It must be 
remembered, however, that symptoms such as 
those mentioned may be due to a great variety 
of causes other than vitamine deficiency. In 
the absence of definite means of diagnosis the 
only evidence of their dependence upon vi- 
tamine deficiency is the therapeutic test, viz., 
prompt and decided improvement which fol- 
lows when foods known to be especially rich 



VITAMINES 201 

in the different vitamines are added to the 
diet, such as orange juice or yeast or cod 
liver oil. 

In this connection one is reminded of the 
patent medicine advertisement which ran 
somewhat as follows: "If you are cured 
you haven't got the disease. The remedy 
never fails." 

From our experience with deficiency diets 
in animals positive results should certainly 
be seen in a few weeks. Definite results in 
man can only be established by careful clini- 
cal observations. It should first be evident 
from an analysis of the diet that a deficiency 
probably exists. The changes made should 
be as carefully planned as are laboratory ex- 
periments with rats or guinea pigs. Other- 
wise the results reported to follow are likely 
to depend upon either the faith or the skepti- 
cism of the observer. 

Some suggestive observations regarding 

the use of antiscorbutic vitamine have been when De- 
ficiency 

made by Hess and others, in which the weight Exists 
curve of infants showed a prompt rise on the 
addition of orange juice to the daily diet; 
but in many or most of these cases the diet 
was known to be, or at least strongly sus- 
pected to be, poor in this factor. 

Some results which may be significant have 



Marked 
Benefit Only 



202 FOOD, HEALTH AND GROWTH 

also been seen to follow the use of cod liver 
oil in certain conditions of malnutrition in in- 
fancy, particularly in premature infants. I 
have myself seen the weight curve of some 
premature infants who had made no gain for 
many days show an immediate rise by no 
other change than the addition of five drops 
of cod liver oil to the daily food. It con- 
tinued while the oil was administered and 
ceased when it was withdrawn. This amount 
is too small to change the energy value of the 
food. The effect noted looks like a specific 
action. It is certainly suggestive. 

Vitamine B has been urged upon the pro- 
fession in the form of yeast as being espe- 
gj»™ Yeast cially important for children who are not 
pointing making the normal gain in weight, who suffer 
habitually from poor appetite and chronic 
constipation, etc. In the discussion at the 
American Pediatric Society meeting in June, 
1921, the practically unanimous opinion ex- 
pressed was one of complete disappointment 
in results obtained and incredulity regarding 
the specific advantages claimed. 

However, in view of the important part 
which we now know to be played by vitamines 
in nutrition, it behooves the physician in all 
cases of malnutrition, particularly when the 
explanation is not obvious, to investigate 



Eesults 



VITAMINES 203 

carefully the character of the food and its 
preparation to discover any errors which 
might result in a vitamine deficiency. Espe- 
cially is this necessary in the case of chronic 
invalids, or of delicate children whose diet 
has become greatly restricted from necessity 
or from caprice, and particularly in the case Benefit from 
of infants whose diet is always a restricted tfon wLn' 
one. But until we have some more certain ciency e*. 

ists, Very 

means of diagnosis than we now possess the Doubtful 
indiscriminate use of vitamines in other cir- 
cumstances than the above, for what is often 
referred to as "general results,' ' is not likely 
to be beneficial; it has no rational basis; it 
should be discouraged; it is hardly scientific 
therapeutics. 

It is most unfortunate that the popular in- 
terest in vitamines which is the result of so 
much recent publicity as has been given to 
this whole subject, should be exploited com- commercial 

. „ ° ' . . . „ , . Exploita- 

mercially. Just now vitamines are m fashion tionunfor- 

• / tunate 

and as much capital as possible is being made 
of this fact. The medical profession at all 
events should not be carried along in the pop- 
ular current. Important and indispensable 
though vitamines are, we must not lose sight 
of the fact that there are many other dietary 
factors equally important. 

The physician can fall into no greater 



204 FOOD, HEALTH AND GROWTH 

error than to assume that vitamine de- 
ficiency is the chief cause of all chronic 
nutritive disorders; just as not very long 
ago these were all referred to auto-intoxica- 
tion and at present a certain group would 
have us believe that they are due to some 
disturbance of the glands of internal secre- 
tion. The use of vitamine s without defi- 
nite indications will be popular for a period 
but like other fads it will pass. With time 
and further investigation their true place 
will be determined, 
what vita- Our knowledge of vitamines has taught the 

mine Inves- . 

tigation necessity of a variety of food and the danger 

Has Taught J , . . 

which follows when conditions make a variety 
impossible. It has taught us also the incom- 
parable value of certain foods, particularly of 
milk, not only in infancy, but during the en- 
tire period of growth ; also the importance in 
the diet of children of the green or leafy vege- 
tables. The chief objections to some like cab- 
bage, lettuce and celery, when used in a raw 
state is the difficulty of making children mas- 
ticate them properly. 

Our knowledge of vitamines has greatly 
helped to put the whole subject of nutrition 
upon a scientific basis. The experimental 
method has been substituted for the empirical 
one in determining the value of the different 



VITAMINES 205 

foods. Formerly we might know that cer- 
tain foods were desirable or necessary; now 
we are able in very many cases to say why 
such is the case, and to determine their pre- 
cise valne in nutrition. What was once little 
more than a suspicion has become definite 
knowledge. 

The discovery of the role of vitamines rep- 
resents another milestone passed on the road 
of scientific progress. It has furnished the 
key to many problems which were before ob- 
scure or altogether insoluble. As in bacteri- 
ology and immunology it is the work of the 
laboratory which has made advance possible. 

The part contributed by the rat — one of 
man 's worst enemies — is a very large and im- 
portant one. For this contribution we should 
perhaps in the future treat him with more 
consideration. 

Until confirmed by clinical experience there 
is however some danger in relying too much 
upon the results of laboratory observations 
upon animals of different species whose 
physiological needs may be different from 
those of human beings. 

To sum up the whole discussion: The 
study of vitamines has taught us several im- summary 
portant things regarding the nutrition of 
children : 



206 FOOD, HEALTH AND GROWTH 

That children should eat a variety of food 
and that especial dangers may follow the 
habitual use of a very restricted diet. 

That milk is the one indispensable food for 
children. The diet during the entire growth 
m period should include if possible whole milk, 
dispensable or if skimmed milk is used, it should be sup- 
plemented by butter. Of the butter substi- 
tutes, those which contain beef fat, mutton fat 
and peanut oil are better than those in which 
other vegetable oils or lard are important 
constituents. 

How much milk or butter is required to 
supply the amount of vitamine A needed we 
do not know. The need would seem to be 
greatest during the period when growth is 
most rapid. From our present knowledge at 
least a pint of milk a day seems desirable. 

That a diet which includes no milk what- 
ever should contain ample amounts of the 
green or leafy vegetables. 

Cereals, particularly those from whole 
grains and potato, are important and ade- 
quate sources of vitamine B. 

Fruits have other uses than as laxatives 
and as sources of mineral salts ; they should 
form a regular part of the diet. 

When fresh fruits are not available dried 
fruits may be given, but they are distinctly in- 



VITAMINES 207 

ferior to canned tomatoes as sources of the 
antiscorbutic vitamine. 

Cabbage is such a rich source of all the vi- 
tamines that it should form a larger part of 
the diet than is usually the case, especially 
since it is cheap and in winter often almost c&lgl 
the only green vegetable available. Unless 
thoroughly masticated raw cabbage is diffi- 
cult of digestion for young children. Cab- 
bage when boiled for one-half hour undoubt- 
edly retains enough of the antiscorbutic fac- 
tor for the needs of the body. Its other vita- 
mines are practically uninjured. 

In normal peace conditions the results of 
vitamine deficiencies are most often seen in 
infancy; very rarely in older children, and 
then only in extreme poverty, in chronic dis- 
ease or in rare cases of very delicate children 
whose diet has become much restricted. 

If the daily diet contains milk, cereals, po- Essentials 
tato, green vegetables, some fruit, one need Sndr©n f 
not fear a vitamine deficiency. 

While these articles are especially rich in 
vitamines, most of our common foods contain 
them. 



CHAPTER V 

Lectuke Five 

Practical Measures for Improving the Nutrition of 
Children 

The practical importance of normal nutri- 
tion to the child is very great, as it not only 
affects his childhood 1 ) but its consequences 
reach forward into adult life. We have come 
so far short of realising what is possible of 
accomplishment, as shown by the low stand- 
ard of health and nutrition which we have 
permitted to exist in our country among chil- 
dren, that it has seemed desirable in this con- 
cluding lecture to consider briefly some of the 
means by which the present situation could 
be improved, applying at many points facts 
brought out in previous lectures. 

Is it possible, is it practicable, so to change 
conditions which affect the nutrition and 
growth of the children of this country as to 
bring about a material improvement? If it 
is possible it should certainly be attempted, 
to this end using all means now available and 

208 



IGNORANCE OF THE EDUCATED 209 

developing new and better ones to supple- 
ment those we have. 

The greatest agencies for promoting re- 
form along any line are publicity and educa- 
tion. This is particularly true of all health ^Great- 
matters. The public must first understand 
and appreciate the need and then be taught 
the remedy and how to apply it. 

In this effort to raise the standard of health 
in children we have to combat not only the 
ignorance of the ignorant, but using Chester 
ton's striking phrase, the " ignorance of the 
educated.' ' People may be intelligent about 
almost everything else, but grossly ignorant 
regarding all the essential rules of healthy 
living. They may be wise in all other practi 
cal matters, but unspeakably foolish with re- 
spect to their children, especially when the 
subject involves discipline and training. 

To improve the nutrition of our children 
is no easy task, nor will the ideal be reached 
in one generation, but great improvement in 
conditions can be brought about in a com- 
paratively short time by well organised intel- 
ligent effort. 

Children may fail to attain normal physi- 
cal development from many causes, some of £S£5a? 
which like a bad inheritance or premature USrSiysi- 
birth reach far back and the consequences of JJmSf^ 61 " 



210 FOOD, HEALTH AND GROWTH 

which can never be wholly overcome, no mat- 
ter what the subsequent life history of the in- 
dividual. Other causes are previous acute 
or chronic illness of a serious nature. In still 
other children normal nutrition may be inter- 
fered with by certain physical defects, such 
as carious teeth, large or diseased tonsils or 
adenoids. Failure in nutrition also may be 
the first and for some time the only obvious 
symptom of the development of some serious 
disease like tuberculosis, nephritis, cardiac 
disease or grave anaemia. In the great ma- 
jority of cases, however, children are below 
normal with respect to their nutrition or fail 
to make normal progress in health and growth 
as a result of improper or insufficient food 
and faulty hygiene. 

To begin with the food. This may be abun- 
dant but lacking in the essential elements for 
growth ; what these are has already been con- 
sidered: An adequate supply of high grade 
Food protein, largely from animal sources; a lib- 

eral amount of fat ; an ample supply of min- 
eral salts for growth of bone ; and finally the 
essential vitamines. All these constituents 
will be supplied in ample amount if milk, ce- 
reals, green vegetables and fruit in reason- 
able quantities form a part of the regular 
diet; but they are not furnished in a diet 



Improper 



CAUSES OF MALNUTRITION 211 

common in many homes, in which the prin- 
cipal articles are coffee, white bread, meat, 
potato and sweets. The cost of such a diet 
equals and often exceeds the more valuable 
one. Insufficient food may be the result of 
economic conditions — witness the numbers of 
children in our cities who go to school with no 
other breakfast than bread and coffee, and 
whose principal lunch is sweets from the 
pushcart. 

Examples of bad food habits are, eating at 
all hours rather than at regular hours; the Hlbitsand 
consumption of sweets and trash between JS™ 
meals, and rapid eating with little mastica- 
tion of food. Faulty hygiene includes over- 
crowding, lack of fresh air in sleeping-rooms 
or school-rooms or lack of opportunity for 
out-door play, late hours, in consequence of 
which the child never gets a proper allowance 
of sleep, and seldom an opportunity for a rest 
in the middle of the day after the age of three 
or four years. Overactivity in the form of 
work or sometimes in play consumes so much 
of the energy value of the food that little or 
none is left for growth. By referring to the 
chart on page 74 it will be observed that if the 
allowance for activity is greater than the 
average, it must be at the expense of growth 
unless the amount of food taken is propor- 



212 



FOOD, HEALTH AND GROWTH 



Weight for 
Height 



The Aver- 
age and the 
Normal not 
the Same 



tionately increased; since the requirements 
for basal metabolism and the loss in excreta 
cannot be reduced. Even habitually bad pos- 
ture is a factor of some importance ; as is also 
chronic constipation from which most of these 
children suffer in consequence of lack of regu- 
larity in habit. There are a great many 
other minor causes which might be men- 
tioned, but the above include the chief ones. 

When is a child to be considered under- 
nourished? When is one to be considered 
well nourished, one might well ask. By far 
the best guide is weight in relation to height. 
I do not think it makes any essential differ- 
erence whether we use the standing or the 
sitting height. The standing height without 
shoes is most generally used. 

The average is not the normal either in 
weight or height. The average is a line ; the 
normal is a zone. Neither weight for age nor 
height for age is of much value in determin- 
ing the question of nutrition. Both are sub- 
ject to wide variations from such causes as 
race, family inheritance, etc., so wide indeed 
as to make these of little interest. Certain 
deviations from the average even of weight 
for height are compatible with good health 
and also with normal nutrition. How wide 
the variation from the average must be, to be 



EVIDENCES OF MALNUTRITION 213 

placed in the abnormal group is an arbitrary- 
question and not all observers agree. The 
great majority, however, have considered that 
if any child under twelve years old is less 
than 10 per cent or more below or 20 per cent 
above average weight for height, he may be 
placed in the normal group, so far as his 
nutrition is concerned. For those over twelve 
years, since growth during the adolescent 
period is more irregular than at an earlier 
age, a slightly wider deviation from the aver- 
age weight for height may be included in the 
normal group. 

But not every child whose weight is proper gggg* 
for his height is to be considered normal. 
Sometimes long continued bad feeding or 
underfeeding may result in children, as in 
laboratory animals, in a great stunting in 
size as well as in weight. The child may 
then show a proper relation of weight to 
height but be far below the normal in both. 
Age, therefore, must be taken into account. 
Of two children of the same height but of dif- 
ferent ages the older should be the heavier. 
Again, there are quite a group of children 
who are not as much as ten per cent below 
normal weight who are not in perfect health 
and who may require attention because of 
teeth, tonsils, glandular enlargements, pos- 



214 FOOD, HEALTH AND GROWTH 

ture, etc., but they can hardly be classed as 
cases of malnutrition. 
t^Gain ^e other important evidence of improper 

Normally nutrition is failure to gain normally in weight. 
Observations must extend over a consider- 
able period before this can be determined. 
Few children, even those in the best of health, 
after infancy gain regularly every month. 
There are often periods of two or three months 
in which very little progress is recorded, when 
no cause can be found sufficient to explain it. 
There are also certain seasonal variations. 
The gain both in height and in weight is usu- 
ally greater from June to December than from 
December to June. But a stationary weight 
for a prolonged period or steady loss at any 
time is a warning which should never be dis- 
regarded. Eegular periodical weighings, 
usually once a month for the average child, 
will make possible the early recognition of 
such conditions as those mentioned and the 
taking of proper steps for their correction. 
Nervous Children who are much below weight for 

tations height usually exhibit other symptoms. 
Nervously two types are met with : One, the 
dull, listless type, not infrequently considered 
subnormal mentally, lacking in energy and 
ambition, easily fatigued, disinclined to exer- 
tion, with poorly developed muscles and 



AMOUNT OP MALNUTRITION 215 

flabby tissues ; the other type, ambitious, often 
excitable, usually hard to manage, energetic, 
in fact overactive, never still, sleepless, fre- 
quently with good muscular development but 
almost no subcutaneous fat. 

If we take the best figures now available, 
at least 20 per cent of our American SSSftr? 
school children show evidence of malnutri- 
tion by the standard previously laid down; 
if we add to this number the proportion of 
those of pre-school age (not infants) and of 
those who leave school and go to work before 
they are fully grown, we obtain a total of 
something between eight and ten millions of 
children in the United States who are not get- 
ting the square deal. In by far the largest 
number, fully four-fifths probably, this is a 
remediable condition and there is no reason 
for its continuance except ignorance and in- 
difference. 

The treatment of this situation must in- 
clude both preventive and remedial measures, 
and of the two the former is vastly more im- 
portant. If preventive measures could be 
generally applied a great improvement would 
result, not only in the health of the children 
but in that of the adults of the country. 

Prevention must begin with the application ^^J 6 
of the principles of eugenics, with suitable 



216 FOOD, HEALTH AND GROWTH 

prenatal care, with maternal nursing and the 
best infant feeding and hygiene. These we 
will pass over, not because we think them un- 
important or unrelated to health conditions 
at a later period, for the state of nutrition 
at each period of life has a very close rela- 
tion to the succeeding one, but the period of 
infancy has been widely studied and is, com- 
paratively at least, well understood. It is 
with the older child that we are now specially 
concerned. 

It is during the period immediately after 
infancy that the child perhaps has been most 
neglected. His hours of feeding, the charac- 
ter of his food and its preparation are in too 
many cases identical with those of the rest 
of the family. He is still a very susceptible 
individual growing rapidly and easily dis- 
turbed by adverse conditions. 

How is he to be reached? Thus far there 

have been no special methods proposed for 

Beaching reaching this class. At present nothing bet- 

schooi ter offers than the use of the same methods 

Child 

and essentially the same agencies as those 
which have been shown to be successful in 
the case of infants. What has been done for 
the infants has been accomplished chiefly by 
the education of the mother through home 
visits of the nurse and attendance at the milk 



EDUCATION OF MOTHERS 217 

station or clinic. There is no reason why the 
same agencies might not accomplish quite 
as much in teaching the mother the physical 
needs of her children from infancy to school 
age. 

At the milk stations and clinics for infants, 
weekly attendance is aimed at and bi-weekly 
attendance is essential to secure proper su- 
pervision of a baby. The greatest motive for 
return visits is the interest awakened in the 
mother in the baby's weight. This is some- 
thing tangible, something she can understand 
and appreciate. If her baby is gaining regu- 
larly, she is happy and satisfied. If not gain- 
ing or if losing, she is disturbed, usually 
enough to make her ready to change hours, 
food or habits to secure improvement. 

Continuous observation upon the weight, 
and opportunity for frequent advice with re- 
gard to minor symptoms, which are insured constant 
by weekly or bi-weekly attendance, make it Necessary 
possible to prevent to a very great degree 
serious disturbances of digestion and nutri- 
tion during the first two years. 

In early childhood visits need not be made 
so frequently ; monthly or bi-monthly attend- 
ance may be quite sufficient. But the en- 
deavour should be made to keep up the same 
interest in growth and weight. At least 



218 



FOOD, HEALTH AND GROWTH 



Eecords 
Essential 



A Complete 

Medieal Ex- 
amination 
on School 
Entrance 



twice a year every child should have a gen- 
eral examination by a physician. 

Eecords are of course indispensable and 
may be continued on cards similar to those 
used for the first year. In an ideal system 
each child on entering school should be able 
to present to the teacher and school phy- 
sician a complete record of the essential 
facts of his life history so far as physical con- 
ditions are concerned. From this time on his 
health record should be a part of his school 
record. Consider for a moment what an ad- 
vantage it would be if such a record were 
available for every child. 

The medical examination on school en- 
trance, especially, should be a thorough one. 
It should certainly include as a minimum 
the weight, height and chest measurement, 
tests of hearing and vision, examination of 
teeth, tonsils and adenoids, the heart, lungs, 
glands, feet and spine. For this the child 
should be stripped and the examination made 
in the presence of the parent. His school 
hours, work, exercise, athletics, etc., could all 
be adjusted on the basis of known facts. 
There would be no unpleasant surprises in 
the discovery of uncorrected defects, for all 
these would have been known and most of 
them remedied before school life was begun. 



REDUCTION OF INFANT MORTALITY 219 

It would be most desirable to have such an 
examination repeated at the beginning of each 
school year. With funds now available or 
likely to be available for several years I fear 
this will be impossible. A thorough semi- 
annual examination should however be made 
of every child whose school work falls much 
below the average and this should include 
mental tests. 

It has been argued by some that the vigour- 3n e iXant 

. n . « , . , . , , Death Rat© 

ous campaign to reduce infant mortality has not a sav- 
merely had the effect of bringing about the unfit but 

. ° ° of theUn- 

survival of the unfit, and that these children fortunate 
are carried through the first year only to suc- 
cumb to other adverse conditions in later 
childhood. The facts do not bear out this con- 
tention. Vital statistics show that with a re- 
duction in infant mortality there has come 
about an even greater reduction in the mor- 
tality for the periods one to two years and 
two to five years. In New York City two 
three-year periods show the following com- 
parison : 

1890-1892 1917-1919 

Deaths under 1 year were 26 per cent of all deaths — 14.4 per cent of all 
1-2 years " 8 " " " " " — 4.0 " " " " 
" 2-5 years " 7 " " " " " — 3.6 " " " " 

The fall in the mortality rate has been a 
gradual and steady one for each of these age 
periods during the entire twenty-seven years. 



220 



FOOD, HEALTH AND GROWTH 



Prevent 
Disease by 
Promoting 
Health 



There can be no escape from the conclusion 
that improved health in one period invariably 
improves the health of the period which suc- 
ceeds it. Healthier infants mean healthier 
boys and girls, and healthier boys and girls 
mean a stronger, more vigourous and health- 
ier generation of men and women. 

"We have already alluded to the fact that 
what has been accomplished in the improve- 
ment of the health of the infant and the 
young child has been the result very largely 
of the education of the parents, particularly 
the mother. This education forms a distinct 
and very important part of the field of public 
health. 

It is coming to be realised that the most 
effective way to prevent disease is to promote 
health. In the campaign against tuberculosis, 
for example, all have come to recognise that 
cleanliness, abatement of the spitting nui- 
sance, proper food, exercise, and most of all 
fresh air, have accomplished far more than 
isolation and medicinal treatment of those 
suffering from the disease. In the world-wide 
campaign against hookworm which is being 
carried on by the International Health Board 
it has been found that while the infected indi- 
viduals in the population can be readily cured, 



HEALTH ED TCATION 221 

little can be accompli slicd in stamping out the 
disease except through education. 

It makes no difference then what the par- 
ticular phase of the health problem is that we personal 

i i • • t Hygiene 

are seeking to solve, whether it is cardiac Essential 
disease, hookworm, tuberculosis or simply 
malnutrition, it all comes back to the educa- 
tion of the individual in matters of personal 
hygiene. To promote health is not quite the 
same as to prevent disease although it invari- 
ably has that effect. It is upon the promotion 
of health that the emphasis in public health 
work is now very properly coming to be 
placed, 

With reference to their children parents 
must not only be taught the extreme suscepti- 
bility of the very young to all kinds of infec- 
tion, and the importance of keeping all sick 
persons from coming in contact with them, 
but emphasis should be placed upon the 
means by which children may be kept well. 
Again, that the function of the young child 
is to grow and that this occurs when proper 
food, fresh air and sleep are furnished. A 
small child is a very delicately constructed 
bit of machinery, easily injured and even put 
completely out of order by improper hand- 
ling. The economic side must also be im- 



222 FOOD, HEALTH AND GROWTH 

pressed, that though meat is cheaper than 

medicine, milk is much cheaper than meat, 

Sfrre bx- an( ^ ^at ^ mess * s mucn more expensive than 

pensive than health. 
Health. 

Again, our foreign population does not ap- 
preciate the fact that in a climate like that of 
our Eastern States, children need a different 
diet from that required for example in South- 
ern Europe, and that the modern Ameri- 
can way of feeding children is really an im- 
provement upon the methods which they have 
followed in their former homes, even though 
they have the authority of centuries of usage. 
But even our native-born American is quite 
as impervious to modern health teaching. 
Dr. Biggs, the pioneer in health education in 
this country, has often said that he could 
teach the foreign population of New York to 
adopt a health measure more readily than the 
native American, and often much more read- 
ily than the medical profession. The for- 
eigner has a respect for authority — or at 
least he once had — which a citizen of free 
America does not possess. 
Health In times of great emergency, as when an 

Reforms 

fromTrigirt epidemic of cholera or plague threatens, peo- 
ple will do almost anything they are told. 
They will avoid stimulants, boil their milk 
and drinking water, practise personal cleanli- 



HEALTH EDUCATION 223 

ness and even clean up their dirty homes. 
But the influence of this is very transient; 
when the scare is over they quickly lapse into 
their former habits. 

When a child is dangerously ill there is 
nothing the average parent will not sacrifice 
to save him. But to save him day by day by 
giving him proper food and training him to 
form proper health habits, is something the 
importance of which most parents do not 
yet see. 

We have not been very intelligent with re- 
spect to our health teaching in the past. For 
the most part we have been endeavouring to 
teach adults to reform, to change their habits fg^ 10 
of eating, drinking, bathing, sleep and exer- Adult3 
cise. But adults do not like to reform. It has 
been difficult, almost impossible to influence 
them to change the habits which they have 
practised all their lives. Their prejudices 
are hard to remove. 

It may well be said of most of the health 
knowledge of adults, not that they are so 
ignorant but in the words of Artemus Ward, 
"they know so many things that ain't so." 
It is pretty clear that we have wasted most 
of our energies because we have begun 
wrong. As it is much easier to form than 
to reform, it becomes perfectly evident that 



224 FOOD, HEALTH AND GROWTH 

if we are really going to change the health 
habits of people we must teach the chil- 
dren. Workers in the health field are be- 
ginning to appreciate the fact that the health 
education of children is the great opportunity 
of the future, as yet scarcely touched. It is 
childhood becoming more and more clear that we have 

is the Time 

begun too late with our health education. 
Childhood is the time before habits have been 
formed and prejudices established. The twig 
is so easily bent in the right direction. 

The health education of the child should be 
begun at an early age and in the home. As a 
matter of fact this is what is always the case, 
although the kind of education given may be 
of a most undesirable sort. But it will be im- 
proved when mothers are better taught and 
when they can be made to realise its value. 
However, even under what may be called fa- 
vourable conditions, the health teaching of 
the home leaves very much to be desired. In 
the homes of the wealthy, intelligent nurses 
and educated governesses sometimes give 
very good health instruction and training; 
but too frequently this is entirely neutralised 
by the example of parents and their indulg- 
ence of the children. The mother who takes 
entire care of her children, even though in- 
telligent in other matters, has usually, with 



HEALTH EDUCATION 225 

her other domestic duties, very little time, 
has seldom the knowledge and still less fre- 
quently realises the importance of the early 
instruction in health matters. Comparatively 
few children in our modern homes have been 
properly trained or taught in matters relat- 
ing to their health. Some other instruction 
than that which a child receives in his home 
must be given, or each generation will go on 
for an indefinite time repeating the mistakes 
of the preceding one. 

Clearly the school is the place where it can £ n et f e c r h ^ 
be done. That systematic instruction in HomST 
health should form part of the school curric- 
ulum and that education in matters of health 
is quite as important as instruction in the 
" three R's" are ideas which are only begin- 
ning to dawn upon the minds of educators. 

The school in many particulars offers 
advantages over the home as a place for 
health instruction. The child goes to school 
expecting to be taught. What his teachers 
tell him or what he learns from a printed page 
has in his eyes an authority which home teach- 
ing does not possess. Besides, during the 
school age the child has already in most in- 
stances begun to rebel against the prohibi- 
tions of the home in which most of the health 
teaching of the home consists. In the health 



226 



FOOD, HEALTH AND GROWTH 



Health 

Made 

Repulsive 



Failure of 
Former 
School 
Teaching 



teaching of the past no effort has been made 
to make health attractive ; too often I fear we 
have succeeded only in making it repulsive. 
A continued repetition of "don't's" and 
"you mustn'ts" has very little influence with 
average boys or girls, whether it relates to 
their speech, their posture, their manners or 
their health. 

Another advantage of the school is the op- 
portunity it affords for the stimulus of emula- 
tion and for group instruction. It is much 
easier to get a group of thirty or forty chil- 
dren in a school room to do things than to in- 
fluence a single child to do them. Children 
at this age are greatly influenced by the opin- 
ions and the conduct of their fellows. Once 
proper health ideas and traditions can become 
established in a school, a public opinion is 
created w T hich makes possible a widely varied 
kind of health teaching. In the. six or eight 
years of school life the child may be made to 
understand the simplest rules of personal 
health and the broader aspeets of public 
health. 

But, some one says, have not our schools 
been teaching physiology and hygiene for 
a generation or more? In the advanced 
grades and in the high-school, yes; but how? 
These subjects have almost without exception 



HEALTH EDUCATION 227 

been made a matter of text-book instruction 
and recitation. Children were taught, for in- 
stance, the number of bones in the body, the 
composition of the gastric juice ; they learned 
that in the lungs the body gives of! C0 2 and 
takes up oxygen; but that those things had 
any relation to the kind of food they should 
eat or to the necessity of keeping the win- 
dows of their sleeping-rooms open, was sel- 
dom even suggested. 

The teaching of these subjects influenced 
the health habits of the pupils no more than 
their study of botany. They were not linked 
up with practical life. A new and more vital- 
ised method of teaching must be devised if re- 
sults are to be obtained. 

A wide, general interest has been awakened 
in the last few years in physical education, 
and this is regarded by many school authori- wm pnysi- 
ties as the solution of the problem of health in tion and " 
the schools. Physical training has been made Accomplish 

J & the Result? 

compulsory in some of our states. Liberal 
appropriations have been made by both state 
and local authorities and the physical di- 
rector is in many places one of the highest 
paid school instructors. All this has been em- 
phasised very largely as a result of the rev- 
elations of the draft which revealed such a 
deplorable condition of physical development 



228 



FOOD, HEALTH AND GROWTH 



Danger of 
Too Much 
Emphasis 
Being 
Placed on 
Field Day 



among our young men, nearly one-third of 
whom were found physically unfit for mili- 
tary service. Whether the problem of the 
health, nutrition and physical development of 
our children is going to be solved along the 
lines of physical education as now conducted 
seems very doubtful. 

The fundamental error appears to me to be 
the belief that all or at least most of the evils 
and failures which have been so obvious can 
be overcome or prevented by exercise, or ex- 
ercises and physical training. Attention is 
too often concentrated upon the gymnasium 
and the showing made on field day. How far 
this is from solving the health problem the 
following incident related to me by a health 
worker in another state will indicate: The 
girl who was taking a leading part in field 
day was in such a poor state of health that 
she was obliged to omit all her school work 
for many days and so exhausted was she 
after going through her part that she was ex- 
cused from her studies and was allowed to 
remain the rest of the day in bed. 

The ambition of school heads to make a 
good showing on field day, especially at inter- 
scholastic meets, and the natural desire of all 
children to take part in such events and to 
excel in them is all very well. It has its ad- 



HEALTH EDUCATION 229 

vantages; but encouraging these things is 
very different from promoting the health and 
best physical development of the school as a 
whole. 

The fundamental mistake made is that exer- 
cise and physical training are too often 
looked upon as ends, not as a means to an 
end. By entirely ignoring the question of 
the nutrition of the pupils, and the effect upon 
it of physical exercises prescribed and actu- 
ally performed, the so-called physical educa- 
tion may result in a positive harm instead 
of benefit to the individual, as in the instance Re st 
above cited. Periods of rest, not hours of Necessary 180 
exercise in the gymnasium, are what very 
many of these children need most. 

It seems quite evident that the problem of 
the nutrition of school children is not going 
to be solved by physical education as now con- 
ceived and administered in the great ma- 
jority of our schools. Instruction in physical 
education is not health teaching in the sense 
that we have in mind. In some states the pro- 
gram for physical education includes much 
more than I have suggested. 

Physical education should certainly include 
the formation of proper health habits. In 
theory this view is held by most teachers 
of physical education, but how little it is 



230 



FOOD, HEALTH AND GROWTH 



Early 

Health 

Teaching 



Value of 
Different 
Methods of 
Education 



emphasised in practice is indicated by the 
syllabus of one state which devotes 285 
pages to a detailed description of exercises 
and but a single paragraph to food habits. 

Health teaching should be begun in the first 
grade at school entrance, and continued 
through all the grades of the elementary 
school. The idea should be grasped at the 
outset that the aim of this teaching is to get 
children to do things. We must not seek, at 
this age, to impart information about health, 
or to teach them to recite the rules of health, 
but to form what we cannot better describe 
than good health habits. 

Lectures and health talks accomplish very 
little with children of any age and nothing at 
all with young children. Such talks when 
made a part of the regular school curriculum 
are likely soon to degenerate into advice as 
to how to prevent taking cold, admonitions to 
wear rubbers, keep out of draughts, avoid 
children who are coughing and sneezing, etc. 
They are a bore both to teacher and pupil. 

To determine the value of different means 
of teaching health to children the following 
experiment was tried upon a large group: 
First, the children were given a talk upon 
health, impressing its value and importance. 



HEALTH EDUCATION 231 

Later they were taken to a health exhibit 
where they were shown with full explanations 
various charts, diagrams, etc. Another day 
they were shown a health film at a moving pic- 
ture theatre. After an interval the children 
were required to write compositions upon 
what they had learned about health. Only 
one or two mentioned the health talk; a few 
the health exhibit, while nearly all described 
fully what they had seen in the picture film. 

Such results are most instructive. They 
show that we must teach health as we teach 
other things successfully, by the use of meth- 
ods which appeal to the child, by things he 
can understand. 

Since our aim with young children is the 
formation of habits, the problem becomes one, 
first, of selecting the most important, and 
then of devising means to secure their con- 
stant repetition until they become automatic. 

The habits stressed by the Child Health 
Organisation are as follows: 

A full bath more than once a week i5!X ial 

Brushing the teeth at least once every day Habits 
Sleeping long hours with windows open 
Drinking as much milk as possible, but no cof- 
fee or tea 
Eating some vegetables or fruit every day 



232 FOOD, HEALTH AND GROWTH 

Drinking at least four glasses of water a day 
Playing part of every day out of doors 
A bowel movement every morning 

These are very simple things, but if regularly 
practised by all children they would certainly 
bring about a very marked improvement in 
their physical condition. To the physician 
these habits are known as the laws of health ; 
to the children they are taught and practised 
as the "Bules of the Game." 

How to get them done by children, not for 
a few days or weeks, but regularly and con- 
tinually during school life — this is the prob- 
lem. 

We must not then make work of our health 
teaching in the school, but seek to make it 
piay Motive P^V > we can £ e ^ children to do almost any- 
thing if it is made play. We should aim to get 
into their minds that health too is a game, 
with its rules like other games ; a game that 
one can win or lose according as he obeys the 
rules. The play motive is altogether the most 
successful one up to the age of ten or eleven. 
Unless the child is interested, it is hopeless 
to attempt to influence him ; so we begin if we 
can with something which is dramatic and 
which will catch the child's interest, like Cho- 
Cho the Health Clown, the Jolly Jester, the 
Health Fairy, or some of the other dramatic 



HEALTH EDUCATION 233 

characters, first developed by the Child 
Health Organisation, who introduce health 
teaching under the guise of amusement or en- 
tertainment. Those who see in the modern 
movement for the health education only 
amusement for an hour, have not grasped the 
point. These things are only the beginnings, how to 
the first lessons in health — kindergarten les- interest 
sons if you will; but they are based upon 
sound psychology — that before you can in- 
fluence, you must interest. 

If one is skeptical regarding the effect of 
such measures let him watch and see how 
much real interest can be aroused, how chil- 
dren are impressed and how well they remem- 
ber what they are taught in this way. Health 
teaching can be correlated with instruction in 
reading, writing and arithmetic without tak- 
ing extra time in the curriculum. 

When a little older, children love organisa- 
tion; at a certain age, usually about twelve 
or thirteen years, they like nothing so much Sotive lub 
as to belong to a club, to wear badges or a 
uniform. Hence the response which has come 
from the Modern Health Crusade movement, 
and the success which has attended the for- 
mation of various types of health clubs or 
health leagues, in which records are kept of 
the daily performance of certain " Health 



234 



FOOD, HEALTH AND GROWTH 



What a 
Teacher 
without 
Special 
Training 
but with 
Enthusiasm 
and Insight 
can Accom- 
plish 



Chores' ' like the Rules of the Game men- 
tioned, and where inspections are made daily 
by the officers to see how well the chores 
have been done. 

All these movements are attempts to capi- 
talise certain instincts of the child, and when 
well administered they can be made of very 
great value. The only difficulty is that after 
a time children almost inevitably lose interest, 
and the continued repetition of the same per- 
formances may become something of a bore. 
Something more must be devised to maintain 
their interest if the health habits we are seek- 
ing to have children form are to become 
habitual with them. 

Eight here is the opportunity for a teacher 
with tact and imagination to utilise any spe- 
cial interest of the child to carry the health 
lesson. The following incident illustrates this 
point : 

Miss M. had been appointed a special 
teacher of an open-air class in one of the pub- 
lic schools of a large city. She became very 
much interested in the health of her boys and 
girls, but she thought: "How can I teach 
them health? I have never had any special 
training in the subject. ' ' One day she had an 
opportunity to talk to an expert on health edu- 
cation who told her that she needed no tech- 



HEALTH EDUCATION 235 

nical knowledge to teach the simple laws of 
health; that any teacher could interest her 
pupils in learning to drink milk, eat green 
vegetables and have plenty of fresh air and 
sleep, if she went about it in the right way. 
She was told of various devices for arousing 
the children's interest but she was not satis- 
fied. Her city street boys were not of the 
type to be interested in fairies. She had 
become enthusiastic, however, over the idea 
of dramatising health education and at last 
she stumbled on the magic word; it was 
" Sport.' ' Her boys were inveterate readers 
of the sporting page and, as it happened, 
horse racing was the particular excitement at 
this time. Miss M. also took to reading the 
sporting page. To her surprise she found it 
to be very stimulating literature. The time 
came for Man o' War's great race. Miss M. 
saw her chance and took it. She discussed 
with the boys what the difference was between 
a race horse and an ordinary horse, and ex- 
plained the wonderful care he received ; how Impor tance 
his coat was washed and brushed every day, ruS? a? 
his mane combed, his food carefully measured ufd Horse 
so that he took neither too little nor too much 
and how it was given at regular hours ; how 
he was given plenty of water at proper times 
but never when he was hot ; how he was exer- 



236 FOOD, HEALTH AND GROWTH 

cised regularly every day out of doors and 
had a nice quiet place to sleep, etc. The in- 
ference was obvious. 

The boys would now come to school ahead 
of time every day to discuss Man o' War with 
Miss M. ; on the day of the race they came a 
whole hour before opening. The next day 
they were asked to write about it. Their com- 
positions showed that the point had been 
driven home, they were fairly bursting with 
the inevitable connection between cause and 
effect. Man o' War had to win because he 
had followed the " rules of the game." One 
little boy wrote: "Gee, if you could have 
seen Man o' War coming around the curve 
with his coat a-shining in the sun you would 
know he just couldn 't help winning. ' ' 

It was not hard after this for Miss M. to 
get her pupils to practise the health rules. 

Special training and equipment are useful 
but not essential. The one thing which is 
indispensable is a person with tact and en- 
thusiasm. Of such material as Miss M. will 
the health teachers of the future be made. 

The dramatic instinct of children can be 
uses of utilised in the production of little health 
piays plays, like those of Eleanor Griffith. With en- 

couragement and a little help from the teach- 
ers, children themselves have written some 



HEALTH EDUCATION 237 

very creditable plays. Milk is most often 
the subject and the different constituents of 
the milk are the different characters. The vil- 
lain of a play is often tea or coffee while milk 
is the heroine. 

The exhibition of good posters in the school- 
room and poster contests among the children 
may be a means of teaching health as well 
as drawing. The contests may be between the Health 
boys and the girls, between different rooms 
in a large school, or the competition may be 
a more general one between all the schools of 
a city or county. Such a competition with 
prizes was recently held in New York; with 
a little newspaper publicity much interest 
was aroused and some very excellent health 
posters produced. All the posters were ex- 
hibited for several days in one of the rooms 
of the Metropolitan Museum of Art and the 
prize posters displayed in a prominent shop- 
window. 

Health rhymes of the sort which appeal to 
children are another way of teaching the 
same lesson. The following by Mrs. Freder- 
ick Peterson are excellent examples : 

There was an old man with a tooth 
That ached till he said, it's the truth, 
I neglected 'em young, and now I am stung. 
How I wish I had brushed 'em in youth ! 



Health Les- 
sons in 
Catchy 
Rhymes 



238 FOOD, HEALTH AND GROWTH 

There was a boy in our town whose mother was not 

wise. 
Coffee and tea he nsed to get and grew up under- 

size. 
Bnt when he failed the football team because his 

size was small, 
He cut out both and took to milk and grew up very 

tall. 

The health lessons stressed in such verses 
are not easily forgotten by children. Why 
should they not be taught them as well as 
Mother Goose rhymes? When accompanied 
by appropriate pictures they form an at- 
tractive decoration for the room of the kin- 
dergarten or the primary class. 

The remarkable success of Mrs. Peterson's 
Child Health Alphabet (nearly two and a 
quarter million copies of which have already 
been distributed) is the most conspicuous ex- 
ample of the need of such literature for small 
children and its value as a means of teach- 
ing them. 

Of all the methods proposed for maintain- 
ing an interest in health matters in children 
of all ages, none has been so generally useful 
weigh? m as that which centers about the weight and 
Lasting height. It is no exaggeration to say that the 
scales have saved the lives of more infants 
than any device of medical or surgical treat- 
ment. 



HEALTH EDUCATION 239 

And right here may I digress and say a 
word with reference to tables giving stand- 
ards of height and weight which have been a 
subject of so much recent discussion as to 
discredit in some quarters their value? The 
differences between nearly all the tables now 
in use are more apparent than real and are 
owing chiefly to the difference in the manner 
of presentation. 

By many who have discussed this subject 
the main point has apparently been missed. 
The chief purpose of weighing children in 
school is not to collect anthropometric statis- 
tics, but to interest children in health. The 
actual relationship between weight and height 
of a child at the beginning of observation is 
of much less importance than his rate of prog- 
ress. It is with the latter that health teaching 
is most vitally connected. 

It is of course necessary that scales should 
be in the schools, and that weights be taken S^g^ord 
regularly during the school year, usually once 
a month. The weights for the children of a 
single room may be entered upon a large chart 
hung in a conspicuous place. Opposite the in- 
itial weight the average weight for the height 
is recorded so that the child can see where 
he stands and what progress he is making 
each month. 



240 FOOD, HEALTH AND GROWTH 

Various other devices are used with the 
younger children. In one primary class- 
room I saw a large sheet of paper upon 
which was drawn the ladder of health, the dif- 
ferent rungs of which are marked from the 
bottom "going up," "almost there/ ' "on the 
level, ' ' " over the top, ' ' each child making his 
own entry after the weighing. The device 
in another room was a row of small paste- 
board clocks, one made by each child, on 
which was shown by the minute hand the ex- 
isting weight, and by the hour hand the nor- 
mal average weight for the child's height and 
age. The minute hand is moved up or down 
as he gains or loses at the monthly weighing. 
These are kindergarten methods, truly, but 
they accomplish the result aimed at — they 
gain and hold the child's interest at a cer- 
tain age. 

One must see one of these monthly weigh- 
ings properly conducted to appreciate their 
significance. They are made important, often 
solemn, occasions, and the interest of the 
children is often intense. The scales are 
placed at the point of the weight taken the 
previous month and when a child steps upon 
the platform eager eyes watch whether the 
bar will rise or fall, indicating a gain or loss 
for the month. When the weighing is finished 



HEALTH EDUCATION 241 

one teacher addresses her children somewhat 
as follows: "Now will every child in the 
room who is up to normal weight for height 
stand up. " " Children, I could tell it by your 
looks; by your bright eyes and rosy cheeks, 
by the work you did in school this month, by 
the way you play at recess, etc., etc." 

All of course are delighted. 

"Now, will every child who gained in 
weight last month stand." 

More words of commendation follow, then 
the teacher says to a group — 

"Now won't you tell us how you did it." 

Many hands go up as each wishes to relate 
his own personal experience. It is not neces- 
sary to call attention to those who did not 
gain or who are below normal weight. 

A common cause of under-weight is that 
the child has no appetite and will not eat 
simple nourishing food. The mother says, 
"he must have some breakfast before school, 
so I give him coffee and a roll, or griddle 
cakes with syrup which he will eat, rather 
than have him go to school with no breakfast 
at all." To change things in the home is 
difficult; in some homes it is impossible, but 
in the school it can be done. The child with 
such habits finds in school that he is at the 
foot of the class in health. To gain he will 



Bad Food 

Habits 



242 



FOOD, HEALTH AND GROWTH 



Creating an 
Ambition to 
be Healtny 



Conditions 
Necessary 
to Gaining 



now go to bed at a reasonable hour, eat his 
cereal and drink his milk and soon he often 
finds he likes them. 

When a child is f onnd at the monthly weigh- 
ing to be much under-weight or not gaining 
he is anxious to know why. He wants to be 
in the healthy group. Now is the opportu- 
nity to stress the health rules. Advice to a 
child who wants to know is never wasted ef- 
fort. He is ready to submit to a medical 
examination, have teeth extracted or tonsils 
and adenoids removed, if these seem to be the 
cause. But the influence of this does not stop 
at the school door; as these health records 
go home to the mother on the monthly report 
card, her interest is awakened and with little 
difficulty her cooperation is secured; in fact, 
the child's zeal makes this almost inevitable. 

The home is reached through the child and 
many a mother may now learn for the first 
time what is a suitable diet for a school child 
and what habits are indispensable for health 
and growth. 

When a child has learned that to get up to 
his normal weight or to gain weight, he must 
be in bed before nine o 'clock and not play in 
the street till ten or eleven; that he must 
drink milk, not tea and coffee; eat regular 
meals, not fill his stomach with sweets and 



HEALTH EDUCATION 243 

other trash between meals, must eat a va- 
riety of food — cereals, vegetables, fruit, etc., 
and not make his entire meal of one thing no 
matter how fond he may be of it — does any 
one suppose that such habits formed in child- 
hood will not make a lasting impression upon 
his life? 

Too much emphasis cannot be placed upon 
the fact that the essentials of personal health 
are such simple things as those mentioned, 
and that even the untrained teacher, once she 
is interested, can carry them into effect. 
Emulation and competition are powerful mo- 
tives in childhood, and while they are often 
unduly stimulated, they are very valuable in- a^loSg 1 
centives to children to do much that is desir- Motive 
able. 

In a school atmosphere like the one de- 
scribed — and this is not a fancy sketch, many 
such exist — such a public opinion as to the de- 
sirability of health exists that nothing can re- 
sist it. Children are taught health songs, to 
produce health plays, to make health posters, 
to devise health games and health charts. One 
must see it to appreciate the interest the lit- 
tle children take in these things, and the fun 
they get out of it ; the pride they take in being 
up to weight and their delight at the regular 
monthly gain. One is touched too by the con- 



244 FOOD, HEALTH AND GROWTH 

scientious efforts of those who are below to 
gain and to bring their weight up to normal. 
One little fellow of seven years I saw who 
was nine pounds below weight and who had 
formerly had coffee three times a day but who 
was bravely drinking his milk and eating his 
oatmeal to be in the healthy group, and 
getting to like them too. Children are taught 
to think health, to live health, not to recite it. 
Much of this is looked upon at first with 
doubt by parents, askance by school boards, 
and with suspicion by physicians; but once 
they witness the results achieved in improved 
physical condition and better school work 
they are compelled to admit its effectiveness 
and its value. 

Children do not by these methods become 
idols not self-conscious regarding their health; noth- 
ing is suggested as to disease, bacteria, the 
dangers of infection, etc. Health as a thing 
to be gained, to be kept and to be enjoyed; 
health as contributing to success in athletic 
games — these are things which are kept be- 
fore their minds. 
Te e a a cMn g Older children can understand also many 

children of the more important problems in public 
health. For instance, the enormous loss of 
life and property in epidemics; the connec- 
tion between them and faulty hygiene and 



HEALTH EDUCATION 245 

sanitation ; the fact that they may be spread 
by unhealthy persons who handle food, or 
through a contaminated milk or water sup- 
ply, or by mosquitoes, flies, rats, lice and 
other vermin, and that many of these diseases 
can be communicated from one person to 
another, and why quarantine is necessary in 
such diseases. They can also be taught to 
appreciate the value of clean streets, the 
necessity of proper disposal of sewage and 
garbage. How diphtheria, smallpox and yel- 
low fever have been conquered, and the re- 
sults of the campaign against tuberculosis 
and typhoid fever, should be known to every 
one, and there is no reason why this might 
not be given in schools. Some of our best 
modern books on hygiene like Winslow's 
"Healthy Living' ' give this information in 
readable form. 

These health stories must be graphically 
told by one who has the gift of writing for 
children and most of all they must be accu- 
rate as to fact and told without exaggeration. 
They must be better than literature which 
was put into our schools regarding the in- 
jurious effects of alcohol. I am reminded 
in this connection of the remark of a boy 
who was gazing out of a sleeping car win- 
dow at a vivid sky at sunrise. "Why, 



246 



FOOD, HEALTH AND GROWTH 



Health 
Taught In- 
cidentally 
to Other 
Subjects 



Mother' ' he exclaimed, "it's just like the pic- 
ture of the inside of the drunkard's stomach 
in my school reader." 

To older children health instruction is best 
given not as a subject by itself but incident- 
ally, correlating it with other subjects of the 
school curriculum. For instance, with history 
and economics, study the failure of the 
French to build a Panama Canal and the suc- 
cess of the United States when Gorgas had 
shown how malarial fever could be stamped 
out; or the cleaning up of Cuba by Leonard 
Wood and the consequent control of yellow 
fever, which previously had been brought 
from Cuba to the ports of New Orleans, 
Mobile and Savannah every few years, caus- 
ing epidemics with thousands of deaths and 
costing millions of dollars by paralysing busi- 
ness in these cities which were sometimes 
quarantined for months. 

In mathematics let the children solve prob- 
lems like this : Calculate the cost of erecting 
and maintaining a water nitration plant for 
a city, and compare this with an annual oc- 
currence of one hundred cases of typhoid 
fever each year, with an average disability 
of eight weeks for each case, without taking 
account of loss of life. 

In debate let them discuss such a question 



HEALTH EDUCATION 247 

as the following: " Resolved that our city 
or town should furnish half a pint of milk 
a day at morning recess to every child 
in the public schools." Think what an op- 
portunity to teach those who take part in 
such a debate the uses and value of milk! 
And what a chance to educate the school 
superintendent if he could be induced to act 
as one of the judges in such a debate ! 

In drawing have the children make posters 
illustrating some health rule, such as an early 
bed hour, sleeping with windows open, drink- 
ing milk, not tea or coffee, etc. 

In English composition tell the story of any 
great health achievement like Jenner's dis- 
covery and then let the children write an ac- 
count of it. 

In biography why should not children in 
school learn as much of the life and work of 
John Harvey as of Galileo ; of Louis Pasteur 
as of Napoleon ; of Lister as of Gladstone ; of 
Eobert Koch as of Bismarck; of Walter 
Reed as of Andrew Carnegie? Appraised 
in terms of their value to the human race, 
is not the influence of the first group 
mentioned quite as important as the sec- 
ond? 

These are only a few suggestions of how 
the teaching of health might be made real 



248 



FOOD, HEALTH AND GROWTH 



The General 
Public Has 
no Back- 
ground of 
Health 
Education 



to older children in the schools without taking 
any time from other studies. Why is it that 
it is so difficult to get popular support for 
advanced public health measures? I believe 
it is chiefly because the great majority of our 
people today have no background of knowl- 
edge regarding these important matters. The 
boys and girls in our schools today will very 
soon form our voting population. If health 
teaching is made a regular part of school in- 
struction it will not be so hard to secure 
necessary health legislation, or to get appro- 
priations voted for adequate health protec- 
tion of the community. 

Very little in the way of apparatus or 
equipment is needed for such health teaching 
as we have suggested. The one thing which 
is essential to success is a teacher with some 
enthusiasm for health; without this the 
monthly weighing becomes a perfunctory 
performance of no interest to the pupils and 
but one more piece of drudgery put on the 
shoulders of the already overworked and 
often undernourished teacher. Its results are 
merely statistics which are required by the 
principal or school superintendent. 

One of the by-products of the plan we have 
described has often been the discovery by the 
teacher herself that she is far below, weight, 



HEALTH EDUCATION 249 

and that the tea and coffee with which she 
seeks to stimulate her jaded nerves, the sweets Effect on 
she consumes because she has no appetite for S e Sr lth 
plain food, and the evenings which she spends Teacher 
in seeking diversion from the deadly routine 
of school work, may have something to do 
with it. The substitution of a quart of milk 
a day for her tea and coffee, eating simple 
food at regular hours and taking one or two 
hours more of sleep a night, are often fol- 
lowed in a few weeks by a gain of six or 
eight pounds in weight; and with this there 
frequently comes an entirely new outlook 
upon life and a different attitude toward her 
work. 

Who is to teach the teacher? "Where is 
she to get the inspiration and the knowledge 
which will enable her to take the initiative in 
maintaining and improving the health of her 
pupils? Our greatest need today in this edu- 
cational health program is trained people to 
teach the teachers; not simply to give them 
the facts of health, but the enthusiasm, which 
is needed to make these things vital in the instruction 
life of the child. This ought to be given in In Health™ 
teachers ' institutes, in our colleges and high- 
schools from which our teachers are recruited, 
and most of all there should be in our nor- 
mal schools up-to-date courses upon health 



250 FOOD, HEALTH AND GROWTH 

education which every teacher should be re- 
quired to take. 

It is impossible here to describe in detail 
how, once the spirit of health teaching exists 
in a school, this teaching can be correlated 
Seacwng 1 * 11 with other school work. It should be closely 
correlated linked up with the Domestic Science Depart- 
ment and the work of the physical director. 
All this can be done without imposing extra 
burdens upon the teacher or the school curri- 
culum. For suggestions along these lines I 
would refer to two pamphlets prepared by 
the Child Health Organisation and issued by 
the Department of Education in Washing- 
ton ; one by Eobert Gr. Leavitt of the Trenton 
Normal School on "The Health of the 
Teacher" and the other by J. Mace Andress 
and Mabel Bragg entitled "Suggestions for 
Teaching Health in the Elementary Schools." 
These are full of practical hints and should 
be in the hands of every teacher. 

While the teacher alone with only the help 
we have mentioned can do a great deal, she 
cannot do it all. She should have the coopera- 
tion of a school nurse and a school physician, 
and in every large town she might have them, 
if parents appreciated their value. 

In an ideal plan, medical school inspection 
should form an important part of such a pro- 



HEALTH EDUCATION 251 

gram as we have outlined, and should be 
closely linked up with other health teaching. 
So also should the hot school lunch, which ^ JJJJJ 
should be looked upon not merely as a means 
of improving the nutrition of the children, 
important though this may be, but as hav- 
ing great educational value. It offers a 
unique opportunity to teach children all 
through their school life food values, food 
costs, what foods are necessary for growth 
and what are undesirable. It has proven of 
the greatest value in teaching children to 
eat proper foods and to connect the child's 
interest in his weight with the selection of 
nutritious food. 

The school nurse is needed to take up de- 
tails with children who are especially in need 
of help. She can go into the home and secure 
the cooperation of the mother. The school 
physician is needed to discover existing dis- 
ease and to see that physical defects are re- 
moved, which may be the cause of the failure 
to make progress Then, too, time must be 
found in the school curriculum for the regu- 
lar weighing and the accompanying health 
teaching. They should not be done out of 
school hours as if they were no real part of 
the school program. 

That education in health should form an 



252 



FOOD, HEALTH AND GROWTH 



Health 
Instruction 
an Essential 
Part of Pub- 
lic School 
Education 



Corrective 
Measures 



integral part of our public school education, 
it seems to me is a position which is unassail- 
able. Next to moral training, more impor- 
tant in its relation to life than anything else, 
is health. The basis of adult health is proper 
nutrition during growth. To insure this is 
one of the great problems before the world 
today. It can come only through an aroused 
and enlightened public opinion. But the 
school is the place where the foundations for 
it must be laid. 

If the general plan of preventive measures 
just outlined is followed, the need for reme- 
dial measures will be greatly reduced. But 
it may be a considerable period before these 
preventive measures are adopted even in en- 
lightened and progressive communities. 
Time will be required to educate public opin- 
ion up to the point of demanding them. Yet 
no matter what preventive measures have 
been adopted, there will always be a certain 
number of children whose nutrition is below 
what it should be. At the present time this 
group is quite a large one. Among the well- 
to-do a child with malnutrition should be un- 
der the care of a private physician, but he 
seldom is except where the parents are un- 
usually intelligent in health matters. Among 
those of moderate means and among the poor 



Class 



NUTRITION CLASSES 253 

such a child seldom sees a physician unless 
really ill. In some communities organised 
effort has been made to solve the problem of tri5on U " 
malnutrition, or at least to help in solving it, 
by the formation of Nutrition Classes. 

It is possible here only to outline the or- 
ganisation of these classes, the methods of 
operation and to indicate the results which 
they have accomplished or may accomplish. 
The purpose of the nutrition class is to help 
by intensive effort, largely educational, the 
group of children who by observations upon 
weight and growth have been found to be so 
far below the normal average standard that 
they are in need of special attention. In New 
York and in other cities such classes have 
multiplied rapidly, especially during the last 
two years. The movement is the outcome 
of the interest in the nutrition of children 
which has been awakened largely by observa- 
tions upon weight made in general school sur- 
veys. It is certainly an important health 
movement and if rightly organised and ad- 
ministered it may do for older children what 
the milk station and the consultation have 
done for infants. 

Classes have been organised in connection 
with schools, settlements, hospitals, out-pa- 
tient clinics, church houses and in many other 



254 FOOD, HEALTH AND GROWTH 

places. They have been conducted by phy- 
sicians, dietitians, trained nnrses, social 
workers, teachers and others, some of them 
well qualified, and some with no qualifications 
at all except a general desire to assist in solv- 
ing a difficult problem. 
Without some medical assistance a good 
organisa- nutrition class is impossible. Before chil- 
Administra- dren are admitted to such a class they should 

tion . J 

receive a thorough medical examination to 
determine whether they are suffering from 
any serious disease, especially tuberculosis, 
to which failure to make normal progress is 
due; also whether there are defects which 
hamper growth, like bad teeth, tonsils, ade- 
noids, etc. For there is little hope of ma- 
terial improvement if there are faulty organic 
conditions which are unrelieved. The assist- 
ance of the physician is necessary not only 
for the recognition of these conditions but 
their correction. 

The next step is a careful investigation 
into the child's diet and his habits; much 
can be learned from the child himself ; but a 
knowledge of home conditions is indispens- 
able. So that there is necessary a three- 
fold history, medical, personal and socio- 
logical. Unless all these matters are thor- 
oughly considered at the outset and definite 



NUTRITION CLASSES 255 

and accurate information obtained regarding 
them, little that is permanent will be accom- 
plished. For very often the causal factor 
of greatest importance will otherwise be over- 
looked. It may be largely poverty that is 
the chief cause — the child does not get enough 
food or the right kind of food for the simple 
reason that there is not money in the house 
to buy it. Cooperation with relief organisa- 
tions may therefore be necessary as the first 
step. In a much larger number of cases the 
great causes, ignorance and indifference, 
must be overcome. 

One must seek to awaken in the child and 
also in the mother a desire for improvement. 
Much the same methods of arousing interest 
may be used as those already mentioned in 
discussing general health teaching in the 
schools, viz., regular weekly weighings and 
the stimulus which comes from the emulation 
of being one of a group. Close individual 
attention is necessary in the beginning until 
each child is well understood. 

One of the great difficulties to overcome 
in nutrition classes is to secure regular at- 
tendance for a period long enough to get re- gS^JjJJf" 
suits. On this account the school seems to be f**l & °°£i 
the most desirable place to conduct them. Sch00ls 
Here in ideal conditions the cooperation of 



256 FOOD, HEALTH AND GROWTH 

the school physician, the school nurse and the 
instructor in domestic science may be of great 
assistance. They should all be members of 
the staff of such an organised class as we 
have in mind. School work need not be inter- 
rupted; although in most cases it must be 
modified to allow time for extra rest periods 
which most of these children require. Open- 
air classes in school are of great assist- 
ance. 

The common practice of many physicians 
of advising removal from school for every 
Removal child whose general condition is much below 
undesirable par, is by no means the best thing for most 
of these children. Control of energies and 
regularity of habits are often better secured 
in the school than in the home. 

What is absolutely necessary is a proper 
adjustment of study, exercise and rest. In 
the school all these can be organised and reg- 
ularly carried out. In the home it is often a 
difficult matter. To be sure, the child is in 
school or under its control only five or six 
hours out of the twenty-four and what goes 
on during the other eighteen hours is also 
very important. 

The plan suggested by Dr. Emerson of hav- 
ing the child keep for several successive days 
of every month a record of exactly what he 



NUTRITION CLASSES 257 

does during each hour when not in school, is 
most helpful. Only in this way can one be 
sure that directions given are actually being 
carried out. The offering of small prizes for 
those making most rapid progress is often 
used as an additional stimulus. 

When a child has reached normal weight 
for height and his faulty habits and physical 
defects have been corrected, he may "gradu- 
ate" from the class. Graduation is accom- 
panied by some ceremony and the graduate 
is given a certificate signed by the person in 
charge of the class and sometimes stamped 
with an impressive red seal. 

A comparison is sometimes made between 
the results in very marked cases of malnutri- 
tion by attendance upon such a nutrition class 
as we have described, and those obtained by 
sending children for a few weeks or even 
longer period to country homes. With the 
latter much more rapid improvement usu- 
ally occurs. A child in two months may 
gain ten or fifteen pounds. But this im- 
provement in the great majority of cases 
is lost almost as rapidly when the child 
returns to his home, to his former diet and his 
old habits. Something more must be done 
for these children than to make them gain 
weight. Unless the acquisition of the extra 



Results 



258 FOOD, HEALTH AND GROWTH 

pounds has been accompanied by some edu- 
cation in health the results are very transient. 
The educational process is slow; it takes time, 
great patience and much ingenuity to get 
and to hold the interest of the children, but 
nothing else produces lasting results. 

Nutrition classes, such as we have been 
considering, need no elaborate equipment; 
fo^su^ess but they do require for success a well trained, 
enthusiastic, resourceful personnel. They 
should be conducted by those who understand 
children and have a genius for influencing 
them; who have also the basic knowledge 
of the foods, diet and hygiene which are 
necessary for children. The cooperation of 
the home must be secured and careful records 
of progress must be kept. A class should 
always have the supervision and assistance 
of a competent physician. 

All this means that not a great deal of this 
can be done by volunteer workers ; by far the 
greater part must be done by a paid staff. 
For intensive work classes cannot be large; 
and for permanent results attendance must 
be continued for a long period, sometimes one 
or two years. Good nutrition classes are 
therefore necessarily expensive and it is im- 
possible for most communities to cover the 



NUTRITION CLASSES 259 

field with anything approaching thorough- 
ness. 

Such classes for those suffering from mal- 
nutrition are to be regarded as curative or 
corrective measures. Since it is more im- 
portant and easier to keep well than to get 
well, the greater emphasis should be placed Prevention 

. t-p , More Im- 

upon preventive measures. If proper health go^ti™* 11 
teaching has been done through the schools assures 
the necessity for nutrition classes will be 
greatly diminished. 

As this work of health education in the 
schools develops it becomes more and more 
clear that children can be interested and 
taught to practise proper health habits 
through class-room teaching which can be 
correlated with the regular studies and with- 
out taking time from them. The one thing 
essential is a teacher with the health point 
of view. What some such teachers, even 
without special training, have accomplished 
shows what is possible. 

One cannot believe that ideas of health and 
the way to gain it can be put into the child's 
mind during his school years by such meth- 
ods as we have been considering, without 
their making a permanent impression. 

If what we are striving for is a better gen- 



260 



FOOD, HEALTH AND GROWTH 



How Better 
Trained 
Parents 
are to be 
Secured 



eration of children we must begin by develop- 
ing a better generation of parents. The glar- 
ing defects at present are in the home. The 
boys and girls now in school will be the par- 
ents of the next generation; we should see 
to it that they have a better preparation for 
their responsibilities than their parents had. 
What is there which prevents it? 

The greatest obstacle in the way of improv- 
ing the health of children is not poverty ; it is 
ignorance and indifference. Dr. Osier put it 
right when addressing a public health meeting 
in Baltimore. He said: "We have a disease in 
this city more widely prevalent than tubercu- 
losis, more fatal than cancer, one that causes 
many more deaths every year than the in- 
testinal diseases of children. ' ' The audience, 
the physicians as well as others, wondered 
what the Doctor had in mind — when after 
continuing in the same strain for some min- 
utes he announced that "the disease is Balti- 
more apathy. ' ' I fear this disease is not con- 
fined to Baltimore. 

The foregoing discussion may be summed 
up in the following propositions which have 
been adopted as the creed of the Child Health 
Organisation : 



CONCLUSION 261 

Every health movement which is to bring perma- 
nent results must have an educational basis. 

It makes no difference what the particular phase 
of the health problem is that we are seeking to 
solve — whether it is cardiac disease, hookworm, 
tuberculosis or simply malnutrition among chil- 
dren — it all comes back to the education of the 
individual in matters of personal hygiene. 

To change the health ideas and the health habits 
of adults is difficult and the attempt very largely a 
failure. 

Health education of the future must be directed 
to the children. 

If all children are to be reached this education 
must be given in the schools. 

In the past most of the health instruction of 
children has succeeded only in making health re- 
pulsive. 

The aim of the Child Health Organisation is to 
make the teaching of health interesting and its 
practice attractive. 

To initiate such a program as we have out- 
lined must be the work of the physician; to 
carry it out is the task of the school authori- 
ties ; it can succeed only when backed by an 
intelligent public opinion. 



APPENDIX 

THE CALORIC VALUE OF COMMON ARTICLES OP FOOD 

Based chiefly on the original tables of Atwater and Bryant and 

upon the calculations of Locke; partly calculated from 

original observations made in the laboratory of 

the Babies' Hospital. 



Meats 
Beef, roast, very lean.... 
Beef, round, fat removed. 
Beefsteak, tenderloin .... 

Lamb, roast 

Lamb chop, tenderloin only 

Chicken, roast 

Turkey, roast 

Beef juice 

Gravy, thick 

Bacon, beechnut, cooked 
dry (raw slice, 13 grains) 

Fish 

Bluofish 

Cod 

Trout, brook 

Shellfish 

Clams, long 

Oysters, medium size 

Soups 

Consomme, canned 

Pea, cream soup 

Other cream soups (aver- 
age of five) 

Vegetable soup 

Tomato soup 

Dairy Products and Eggs 
Milk, whole, 3.5% fat... 
Skimmed milk, fat-free.. 

Buttermilk, fat-free 

Cream, light, 20% fat... 
Cream, heavy, 40% fat... 
Condensed milk, sweetened 

Butter 

Egg, whole 

(Wt. with shell, 58 
grams.) 

Egg, yolk 

Egg, white 

Vegetables 
Baked beans, home-made. 

Lima beans whole 

String beans 

Beets 

Cabbage 

Carrots 

Cauliflower 



Quantity 



loz.* 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 

1 slice 



1 oz. 
1 oz. 
1 oz. 



4 oz. 

4oz. 



4 oz. 
4 oz. 
4 oz. 



1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 

1 level tsp. 
1 



1 oz.** 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 



Weight 
grami 



20 
20 
20 
20 
20 
20 
20 
30 
30 

3.5 



150 
85 



120 
125 

125 
125 
125 



33 

20 

so 

35 
30 
33 

20 



Fat 



3.0 
14.3 
37.8 
23.7 
23.7 

8.1 
34.0 

6.2 
44.0 

20.0 



8.G 
0.6 
4.4 



14.0 
9.5 



78.6 



1.8 




55.9 
111.5 
28.2 
39.7 
55.0 



54.0 
1.0 



26.4 
1.3 
3.0 
0.3 
0.8 
0.5 
0.8 



Carbo- 
hydrate 



1.7 



12.0 



1.4 
1.2 



12.2 
12.9 



57.6 

29.7 
23.0 
27.7 



5.9 
5.8 
5.0 
2.9 
2.5 
81.5 



29.8 
24.2 
3.0 
10.5 
7.2 
4.7 
3.8 



Protein 



19.0 
22.7 
19.2 
16.3 
16.3 
26.2 
23.0 
1.8 
6.0 

5.0 



21.4 
18.0 
17.4 



52.8 
21.6 



12.0 
25.8 

13.2 
18.0 
12.4 



4.3 
4.2 
4.0 
3.2 
2.0 

13.3 
0.3 

30.0 



12.0 
18.0 



9.8 
6.5 
1.0 
3.2 
2.0 
0.8 
1.4 



Total 



25 



14 
162 

126 
43 
49 



20 

10 

9 

62 

116 

123 

40 

85 



* Cut in small pieces and measured by volume ; 1 oz. approximately 1 round table- 
spoonful. 

** 1 oz. by volume approximately 1 round tablespoonful. 

265 



266 



APPENDIX 



Quantity 



Weight 
grams 



Fat 



Carbo- 
hydrate 



Protein 



Turnips 

Spinach 

Corn (cut off ear) 

Onions 

Peas 

Asparagus tips, mashed . . 

Potato, white 

Potato, sweet 

Potato, baked, medium size 

Celery, one stalk 

Tomato, medium size 

Lettuce 



1 oz.* 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 

1 

4 in. long 

1 

lleai 



Bread 
White, baker's, slice 3X4 

X y 2 in 

Whole wheat, slice 3X4X 

y 2 in 

Rolls, French, 4X2X1% 



30 
30 
80 
8 
100 
10 



30 



40 



Corn bread, piece, 3y 2 X 

4Xy 2 in 

Zwieback, small piece .... 

Crackers 
Graham, 3X3 in 

Saltines, 2 in. square .... 
Uneeda biscuit, 3 in. square 
Wheatsworth, 2 X 3 in. 

Cereals 
Farina and Cream of 

Wheat 

Hominy, boiled 

Cornmeal 

Oatmeal 

Cornflakes 

Rice, boiled 

Macaroni, boiled 

Shredded wheat biscuit. . . 



1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 oz. 
1 



40 
7.5 



8.0 
3.0 
6.0 
6.0 



0.5 
1.7 
3.3 
0.6 
0.9 
0.5 
0.3 
1.8 
0.5 
0.1 
1.8 
0.3 



3.6 
3.5 
9.1 

17.0 

7.2 



7.0 
3.4 
5.0 
5.3 



0.9 
0.2 
0.3 
3.2 
0.4 
0.3 
4.5 
3.8 



5.8 
23.4 

6.8 
18.6 

4.2 
28.2 
33.7 
70.0 

1.4 
16.4 

1.2 



65.2 
85.6 
89.1 
74.1 



24.4 

8.4 

17.7 

18.2 



14.1 
13.4 
12.3 
13.5 
9.4 
30.3 
21.4 
92.7 



One rounded tablespoonful of cereal = 1 ounce by volume 
One heaping tablespoonful of cereal = iy 2 ounces by volume 

Fruits, Fresh 
Apple, medium, 3% in. 

diameter 

Grapefruit, medium, 4 y 2 

in. diameter 

(3y 2 oz. juice) 
Orange, large, 3% in. di- 
ameter 

(5y 2 oz. juice) 
Peach, large, 2% in. diam 



1.6 
4.5 
3.3 
1.6 
8.5 
2.3 
3.5 
2.5 
8.5 
0.5 
4.8 
0.5 



11.2 

16.7 

13.6 

12.6 
3.2 



3.6 
1.2 
2.3 
2.5 



2.0 
1.4 
1.4 
3.3 
1.2 
3.4 
4.1 
12.5 



Pear, medium, 2y 2 in. diam. 1 



200 


5.5 


88.3 


2.2 


250 


1.1 


55.2 


2.7 


300 


2.4 


87.3 


6.3 


128 
[ .150 


1.0 

5.8 


40.4 
81.0 


2.6 
3.2 



1 oz. by volume = 1 round tablespoonful. 



APPENDIX 



2G7 



Quantity 



Strawberries, medium, 

1 in. diameter 

(1V& ob. mashed) 

Banana, average, 7 in. 
long (100 grams peeled) 

Orange juice 



Fruits, Dried 

Apricots, large 

Dates, large 

Figs, largo 

Prunes, large 

Raisins, large 



Fruits, Cooked 

Apple sauce 

Prune pulp 

Marmalade, orange 

Jelly, currant 

Apple, baked, large 

Peaches, canned, large, 2% 



Peaches, canned (juice 
24% sugar) 



Cakes, Pastries, Puddings 
Cookie, 3 in. diameter. . . 
Gingerbread, 1X2X3 in. . 
Sponge cake, 2X3V2XV2 

in 

Lady finger, 4 in. long . . . 

Apple pie, % pie 

Custard pie, Vq pie 

Bread pudding 

Rice pudding 

Baked custard (8 oz. milk, 

1 egg, 1 oz. sugar) 
Junket (8 oz milk, 1 oz. 

sugar) 

Apple tapioca 

Chocolate cornstarch 

Ice cream * 

Orange ice 

Tapioca pudding 



Sugar, etc. 

Sugar, granulated 

Domino, half size 

Domino, cube 

Honey, 20 c. c 

Maple syrup, 20 c. c 

Karo corn syrup, 20 c.c. 
Ice cream soda 



1 

1 oz. 



1 oz. 
1 oz. 
1 oz. 
1 oz. 

1 



2 halves 



1 

1 piece 

1 piece 
1 

1 piece 
1 piece 
1 oz. 
1 oz. 

1 oz. 

1 oz. 
1 oz. 
1 oz.. 
1 oz. 
1 oz. 
1 oz. 



1 level tsp. 

1 

1 

1 tbsp. 

1 tbsp. 

1 tbsp. 

1 



Weight 
grams 



160 
30 



40 

42 

100 

100 

12 



35 
35 
35 
35 
120 

120 



9.5 

60.0 

23.0 

20.0 

126.0 

133.0 



Fat 



6.0 
0.6 



3.7 
9.7 
2.6 



"'•3.5' 


1.7 


' ' b'.i ' 


5.4 


1.1 



8.1 

50.3 

22.9 
9.2 
114.9 
77.8 
13.2 
15.7 

17.0 

9.7 

0.6 

24.4 

28.5 

0.5 

18.2 



,S£& *»*■ 



94.7 



92.8 
14.4 



102.5 
120.0 
296.3 
254.6 
35.2 



35.8 

38.2 

103.9 

111.5 

120.1 

46.6 

33.0 



31.0 
156.4 

62.2 
57.8 
221.1 
142.2 
47.2 
35.4 

13.5 

13.8 
35.1 

38.0 
22.0 
91.8 
29.2 



25 

25 

29 

100 



161.9 



2.0 



5.2 
1.0 



7.8 
3.3 
17.1 
7.4 
1.3 



0.5 

1.8 
0.8 
1.5 
2.5 

3.3 



2.9 
14.3 

6.0 
7.0 
16.0 
23.0 
7.6 
8.9 

6.5 

4.5 
0.3 
6.6 
6.5 

1.7 
7.6 



1.0 



Total 



104 
16 



114 
133 
316 



10 



38 

40 

105 

113 

128 

51 

33 



42 
221 

91 

74 

352 

243 

68 
60 

37 

28 



25 
25 
29 

101 
88 
95 

278 



* Made with egg. 



268 



APPENDIX 









CALORIES 




Quantity 


Weight 
grams 


Fat 


Carbo- 
hydrate 


Protein 


Total 




1 oz. 

1 piece 
1 piece 

1 

1 

loz. 
1 oz. 
Itsp. 
1 tsp. 
10 

1 


10 
28 

7 

27 

25 
30 

2.5 

9 
20 

4 


36.0 

29.0 
20.2 

0.3 



235 

43 
6.8 

39.0 

54 

25.3 


112.0 

26.0 
46.5 

26.7 

107.0 


12.8 

3.9 

6.3 
15.0 

2.4 


4.0 

3.0 
3.3 







5.2 

2.3 
10.7 
16.0 

3.3 


152 


Milk chocolate, 1X2X^4 


58 


Fudge, 1X1X% in 

Peppermints, plain, 1 in. 

diameter 

LoUypop, 1%X% in. di- 


70 

27 

107 


Mtscellaneous 


235 




61 




13 




56 




85 


Walnuts 


31 



INDEX 



Accessory food factors (see Vi- 
tamines). 

Activity, caloric requirements for, 
55. 
increased caloric requirements 
during, 67. 

Adolescence, food requirements 
during, 66. 
food needs greater during, 76. 

American children, size of, 20. 

Amino-acids, essential for growth, 
89. 

Antiscorbutic foods, 177, 183. 

Antiscorbutic vitamine (see Vi- 
tamine C). 

Ayers, on school retardation, 23. 

Balanced ration, importance of, 
147. 

Benedict and Talbot, basal re- 
quirements, 50. 

Beriberi, 152, 172. 

Blanton, on German children with 
malnutrition, 30. 

Bloch, eye disease in infants from 
deficiency of fat, 163. 

Bones, salts needed for, 139. 

Bryant, school survey, 25. 

Cabbage, 207. 

Calcium, milk important source, 

138. 
California children, size, 21. 
Caloric requirements, basal, 50. 

for growth, 54. 

for activity, 55. 

estimate of, 60. 

complete daily schedule, 73. 



Calorie, definition, 47. 
Calories, for basal metabolism, 50. 
growth allowance, 54. 
activity allowance, 55. 
excreta allowance, 60. 
total requirements, 60. 
per kilo, 65. 

complete schedules per kilo, 67. 
complete schedules, daily re- 
quirements, 73. 
taken by 100 healthy children, 

78. 
table giving suggested total 

daily, 84. 
distribution of in diet, 139. 
Camerer, total calories, 61, 65. 
protein intake, 100. 
fat intake, 117. 
distribution of calories, 146. 
Candy, consumption of, 124. 
Carbohydrate, functions of, 120. 
requirement, 120. 
intake of infants, 123. 
of older children, 124. 
of adults, 126. 
tendency to overfeed with, 124. 
proportion taken as sugar, 128. 
and dental caries, 131. 
amount recommended, 132. 
Carbohydrates, effect of excess of, 
37, 129, 131. 
economical, 121. 
Chick and Hume, observations on 
vitamine C, 182. 
amount of vitamine required for 
protection, 197. 
Child Health Organisation, creed 
of, 260. 



270 



INDEX 



Club motive, use of in health in- 
struction, 233. 

Condensed milk, effects of, 130. 

Cow's milk, low in iron, 137. 

Czerny and Keller, Mehlnahr- 
schaden, 165. 

Deficiency diseases, 44. 

Dental caries and carbohydrates, 

131. 
Detroit, school survey, 27. 
Draft, results of, 7. 

Education, of parents, 10, 260. 
importance of, in nutrition prob- 
lem, 209. 
disease prevented by, 220. 
of adults, difficult, 223. 
Eijkman, early observations on 

beri-beri, 173. 
Energy, definition, 87. 
Excreta, calories lost in, 58. 

Fat, requirement, 107. 
function of, 108. 
effect of, on mineral metabo- 
lism, 111. 
starvation and susceptibility to 

infections, 112. 
intake of nursing infant, 115. 
of artificially -fed infants, 116. 
of older children, 116. 
of adolescent boys, 118. 
symptoms due to excess of, 118. 
amount recommended, 120. 
Fat-soluble vitamine (see Vita- 
mine A). 
Food, influence of, on growth, 17. 
of Japanese children, 18. 
requirements, 47. 
valued by vitamine content, 191. 
Foods, injured by preservation and 
storage, 192. 
infant, deficiency in vitamines, 
199. 
Funk, observations on beri-beri, 
152. 



Gephart, observations at St. Paul 's 

School, 62, 100, 117, 125. 
Gillett, caloric intake, 60. 

protein intake, 99. 
Gillett and Sherman, calorie in- 
take, 66. 
Government, expenditure for De- 
partment of Animal Industry, 
14. 
appropriation for Children 's 
Bureau, 15. 
Growth, determined by food, 
18. 
of Japanese children, 19. 
effects of prolonged underfeed- 
ing on, 42. 
caloric requirements for, 52. 
estimated calories needed for, 

54. 
amino-acids necessary for, 89. 
protein allowance for, 92. 
Growth rate, 52. 

Habits, bad, a cause of malnutri- 
tion, 211. 
formation, essential to health, 
231. 
Hart, Steenbock and Ellis, vita- 
mine content of cow's milk, 
187. 
Health, competition in, 242. 
municipal appropriations for, 
15. 
Health education, preventing dis- 
ease by, 220. 
in home, 224. 
in school, 225. 
by older methods, 226. 
successful and unsuccessful 

methods in, 230. 
play motive in, 232. 
club motive in, 233. 
of older children, 244. 
of teacher, 248. 
correlated with other school sub* 
jects, 246, 250. 
Health habits, 231. 



INDEX 



271 



Health literature for children, 238. 

plays, 230. 

posters, 237. 

rhymes, 2.'} 7. 
Hess, on antiscorbutic vitamino, 

201. 
Hill, observations in Germany, 

57. 
Hopkins, early observations on vi- 

tamines, 152. 
Hoist, scurvy in animals, 158. 

Infancy, period of susceptibility 
to vitamine deficiency, 198. 

Infection, resistance to, dependent 
upon nutrition, 33. 
susceptibility of delicate chil- 
dren to, 35. 

Iron, deficiency of, in cow's milk, 
137. 

Japanese children, food of, 18. 

growth of, 19. 
Jews, Kussian, growth of, in 
U. S., 20. 

Kerato-malacia, 163. 

Lard, vitamine A in, 189. 
Lusk, estimate for caloric require- 
ments, 56, 67. 

Malnutrition, extent of, 8, 215. 

nervous symptoms in, 31, 214. 

causes of, 209. 

evidences of, 214. 

prevention of, 215. 
McCollum and Davis, on vitamines, 

155. 
Medical school examinations, 218. 
Mehlnahrschaden, 165. 
Metabolism, definition, 47. 

basal, 50. 
Milk, an important source of cal- 
cium, 138. 

effect of heating, on vitamine 
C, 178. 



Milk, importance of during 
growth, 806. 
amount required, 206. 

Min.T.-il Baits, functions of, 135. 
Mortality, infant, reduction of, 

5, 219. 
Miiller, on 08 lories lost in ex- 
crota, 59. 
on protein intake, 100. 
on tat intake, 117. 

Nervous symptoms, and malnutri- 
tion, 31, 214. 
Noel and Paton, observations an 

Vienna children, 43. 
Nutrition, factors influencing, 17. 
importance of in treatment of 

disease, 36. 
in chronic disease, 38. 
in organic disease, 39. 
in chronic nervous disease, 41. 
practical measures for improv- 
ing, 208. 
weight-height relationship, index 
to, 212. 
Nutrition classes, 253. 

Orange juice, amount needed to 

protect against scurvy, 182. 
Osborne and Mendel, effect of dif- 
ferent proteins on growth of 
rats, 93. 
of salts, on growth of rats, 

93. 
of vitamine B, on growth of 
rats, 170. 
low-fat diet, 109. 
early observations on vitamines, 
154. 
Oxidation, effect of, on vitamines, 
185. 

Packer and Moehlman, school sur- 
vey by, 27. 

Parents, education of, 10, 260. 

Paton and Watson, observations 
on rickets, 168. 



272 



INDEX 



Physical education and training 

not health teaching, 227. 
Play motive, use of in health in- 
struction, 232. 
Porter, observations on growth and 

school progress, 24. 
Pre-school child, neglect of, 6. 

ways of reaching, 216. 
Preventive medicine, opposition to, 

12. 
Protein intake of healthy children, 

101. 
Proteins, composition of, 88. 
adult requirement, 90. 
animal, preferable for growth, 

90, 92. 
animal vs. vegetable, 91, 106. 
growth allowance, 92. 
effect of different, on growth of 

rats, 93. 
in woman's milk, 94. 
in cow's milk, 96. 
in condensed milk, 97. 
amount needed by infants tak- 
ing cow's milk, 98. 
amount for older children, 99. 
amount per kilo, 103. 
vegetable, of lower grade, 
106. 

Rickets, causes of, 167. 
Eoss, on kerato-malacia, 164. 

School retardation, 22. 

Scurvy, a deficiency disease, 

157. 
time required to produce, 180. 
Smith, Theobald, observations on 

scurvy in animals, 158. 
St. Paul's Sehool, calories taken 

by boys in, 62. 



Tigerstedt, on total calories, 62. 

Underfeeding, effects of, 3. 
arrest of growth in, 42. 



Vegetables, importance of, 170, 

176, 204. 
Vitamine A, 157. 

sources of, 159. 

symptoms due to deficiency of, 
161, 163. 
Vitamine B, 157. 

sources of, 169. 

symptoms due to deficiency of, 
171. 
Vitamine C, 159. 

not needed by certain animals, 
175. 

sources of, 176. 

injured by heat, 176, 179. 

small amount of in milk, 178. 

amount needed for protection 
against scurvy, 181. 
Vitamines, 149. 

early observations of Hopkins 
on, 152. 

effect of oxidation on, 185. 

solubility of, 186. 

effect of food upon amount of, 
in cow's milk, 187. 
in woman's milk, 187. 

in diet of nursing mother, 187. 

deficiency of, when likely, 
195. 

requirements, conditions affect- 
ing, 197. 

deficiency of, in infancy, 198. 

specific action of, 199. 

symptoms due to relative de- 
ficiency of, 200. 

commercial exploitation of, 
203. 

use not indicated when no de- 
ficiency, 203. 
Von Groer, infants on fat-free 
diet, 110. 

War edema, 165. 

Washington, survey of school chil- 
dren in, 26. 

Water-soluble vitamine (see Vita- 
mine B). 



INDEX 



273 



Weighing, how used in health edu- 
cation, 240. 

Weight-height relationship, an in- 
dex to nutrition, 212. 

Weight records, value and purpose 
of, 238. 

White wheat flour, advantages and 
disadvantages of, 192. 



Whole wheat flour, advantages and 
disadvantages of, 1 ( J3. 

Xerophthalmia, 162. 

Yeast, vitamines in, 155. 
in malnutrition, 202. 



